Provider Demographics
NPI:1639263882
Name:DICK, CHARLES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:DICK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 ROUTE 76 SOUTH
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08242
Mailing Address - Country:US
Mailing Address - Phone:609-741-6363
Mailing Address - Fax:609-939-4450
Practice Address - Street 1:1076 ROUTE 76 SOUTH
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:NJ
Practice Address - Zip Code:08242
Practice Address - Country:US
Practice Address - Phone:609-741-6363
Practice Address - Fax:609-939-4450
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08366902084P0800X
DEC1-00027152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC29035Medicare UPIN