Provider Demographics
NPI:1548245590
Name:LIVOTI, CHARLES C (DO)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:C
Last Name:LIVOTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 SOUTH WELLWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757
Mailing Address - Country:US
Mailing Address - Phone:631-226-8600
Mailing Address - Fax:631-957-7858
Practice Address - Street 1:502 SOUTH WELLWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757
Practice Address - Country:US
Practice Address - Phone:631-226-8600
Practice Address - Fax:631-957-7858
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01919433Medicaid
NY794981Medicare ID - Type Unspecified
G68839Medicare UPIN