Provider Demographics
NPI:1770997587
Name:WISNIEWSKI, CHARLES (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:WISNIEWSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:4641 ROOSEVELT BLVD STE E223
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2343
Mailing Address - Country:US
Mailing Address - Phone:631-831-4053
Mailing Address - Fax:
Practice Address - Street 1:4641 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2343
Practice Address - Country:US
Practice Address - Phone:215-831-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0191212084P0800X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1770997587Medicaid