Provider Demographics
NPI:1790782969
Name:CHARLES, JEAN CLAUDE (MD)
Entity Type:Individual
Prefix:
First Name:JEAN CLAUDE
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12930 135TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3542
Mailing Address - Country:US
Mailing Address - Phone:347-522-7547
Mailing Address - Fax:347-789-5533
Practice Address - Street 1:68 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-6705
Practice Address - Country:US
Practice Address - Phone:718-484-8056
Practice Address - Fax:718-484-8325
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-03
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY199884208000000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01598874Medicaid
NY199884OtherLICENSE