Provider Demographics
NPI:1619165404
Name:MILLAN, CHARLES ANTHONY (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:MILLAN
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2957
Mailing Address - Country:US
Mailing Address - Phone:718-494-8595
Mailing Address - Fax:718-494-0191
Practice Address - Street 1:390 MANOR RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-2957
Practice Address - Country:US
Practice Address - Phone:718-494-8595
Practice Address - Fax:718-494-0191
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003366-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ0633Q5JK1Medicare PIN