Provider Demographics
NPI:1710149356
Name:FASANYA, CHARLES TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TIMOTHY
Last Name:FASANYA
Suffix:
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 1:707 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2650
Mailing Address - Country:US
Mailing Address - Phone:845-333-1114
Mailing Address - Fax:845-333-2645
Practice Address - Street 1:707 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2650
Practice Address - Country:US
Practice Address - Phone:845-333-7575
Practice Address - Fax:845-333-1454
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08347800208600000X
NY2546982086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY254698OtherNEW YORK STATE LICENSE
NJ25MA08347800OtherMEDICAL LICENSE
NJ0181781Medicaid
NJ143139A00Medicare PIN
NJ143139NAHMedicare PIN