Provider Demographics
NPI:1295764876
Name:HYDE, CHARLES I (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:I
Last Name:HYDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:IRA
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:72 CIRCUIT RD
Mailing Address - Street 2:
Mailing Address - City:TUXEDO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:10987-4046
Mailing Address - Country:US
Mailing Address - Phone:617-734-5984
Mailing Address - Fax:
Practice Address - Street 1:212 CANAL ST
Practice Address - Street 2:SUITE 206
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4155
Practice Address - Country:US
Practice Address - Phone:212-349-5799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0510512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2008441Medicaid
MA2008441Medicaid
MAA39437Medicare ID - Type Unspecified