Provider Demographics
NPI:1659363893
Name:COLODNY, CHARLES S (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:COLODNY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:716 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3225
Mailing Address - Country:US
Mailing Address - Phone:847-362-1393
Mailing Address - Fax:847-362-3797
Practice Address - Street 1:716 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3225
Practice Address - Country:US
Practice Address - Phone:847-362-1393
Practice Address - Fax:847-362-3797
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036057093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057093Medicaid
ILC44821Medicare UPIN
IL036057093Medicaid