Provider Demographics
NPI:1669405346
Name:INTENZO, CHARLES M (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:INTENZO
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 1:111 S. 11TH STREET
Mailing Address - Street 2:SUITE 3390
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-2900
Mailing Address - Fax:215-923-1562
Practice Address - Street 1:111 S. 11TH STREET
Practice Address - Street 2:SUITE 3390
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-2900
Practice Address - Fax:215-923-1562
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD025932E2085R0202X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001073932Medicaid
NJ6377505Medicaid
PA0010739320009Medicaid
PA087706Medicare PIN
NJ6377505Medicaid
PA001073932Medicaid