Provider Demographics
NPI:1932275963
Name:VACCARIELLO, CHARLES JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOHN
Last Name:VACCARIELLO
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 1:300 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-3210
Mailing Address - Country:US
Mailing Address - Phone:631-765-1104
Mailing Address - Fax:
Practice Address - Street 1:2092 JERICHO TPKE STE 5
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3008
Practice Address - Country:US
Practice Address - Phone:631-343-7611
Practice Address - Fax:631-343-7612
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104837208800000X, 332900000X, 207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No208800000XAllopathic & Osteopathic PhysiciansUrology
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00631190Medicaid
B16557Medicare UPIN
NYB16557Medicare UPIN
NY563891Medicare PIN