Provider Demographics
NPI:1922034628
Name:DACKIS, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:DACKIS
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 1:51 N 39TH ST
Mailing Address - Street 2:DEPARTMENT OF PSYCHIATRY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-8752
Mailing Address - Fax:215-222-3807
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-8752
Practice Address - Fax:215-222-3807
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052016L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017539650001Medicaid
B14861Medicare UPIN
PA0017539650001Medicaid