Provider Demographics
NPI:1912069493
Name:CHARLES, ANTOINE VICTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTOINE
Middle Name:VICTOR
Last Name:CHARLES
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 1:20809 HILLSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427
Mailing Address - Country:US
Mailing Address - Phone:718-776-1013
Mailing Address - Fax:718-776-5549
Practice Address - Street 1:20809 HILLSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427
Practice Address - Country:US
Practice Address - Phone:718-776-1013
Practice Address - Fax:718-776-5549
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00368474Medicaid
E15359Medicare UPIN
NY98954Medicare ID - Type Unspecified