Provider Demographics
NPI:1902856396
Name:ROOT, JAMES CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CHARLES
Last Name:ROOT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 YORK AVE
Mailing Address - Street 2:BOX 140 F1302
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4805
Mailing Address - Country:US
Mailing Address - Phone:212-746-5936
Mailing Address - Fax:
Practice Address - Street 1:1300 YORK AVE
Practice Address - Street 2:BOX 140 F1302
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4805
Practice Address - Country:US
Practice Address - Phone:212-746-5936
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68015884103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVM4501Medicare ID - Type Unspecified