Provider Demographics
NPI:1598754509
Name:CHARLES, LYDIA (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 ROUTE 23
Mailing Address - Street 2:SUITE 350
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7501
Mailing Address - Country:US
Mailing Address - Phone:973-521-9700
Mailing Address - Fax:973-521-9707
Practice Address - Street 1:1680 ROUTE 23
Practice Address - Street 2:SUITE 350
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7501
Practice Address - Country:US
Practice Address - Phone:973-521-9700
Practice Address - Fax:973-521-9707
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA062358002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA06235800OtherMEDICAL LICENSE