Provider Demographics
NPI:1790837714
Name:LOUIS CHARLES, MARC-ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC-ANTHONY
Middle Name:
Last Name:LOUIS CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARC-ANTHONY
Other - Middle Name:
Other - Last Name:LOUIS CHARLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:334 W MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3249
Mailing Address - Country:US
Mailing Address - Phone:516-608-6777
Mailing Address - Fax:516-608-8918
Practice Address - Street 1:334 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520
Practice Address - Country:US
Practice Address - Phone:516-608-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01159631Medicaid
NY01G62Medicare ID - Type Unspecified
01G622Medicare ID - Type Unspecified
NYF16691Medicare UPIN
NY01G621Medicare ID - Type Unspecified