Healthcare Provider Details

I. General information

NPI: 1457798134
Provider Name (Legal Business Name): CHARLES FREDERIC LORTIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 SOUTH STREET SUITE 1 AFFILIATED DERMATOLOGISTS & DEMATOLOGIC SURGEONS
MORRISTOWN NJ
07960
US

IV. Provider business mailing address

182 SOUTH STREET SUITE 1 AFFILIATED DERMATOLOGISTS & DEMATOLOGIC SURGEONS
MORRISTOWN NJ
07960
US

V. Phone/Fax

Practice location:
  • Phone: 973-267-0300
  • Fax: 973-984-2670
Mailing address:
  • Phone: 973-267-0300
  • Fax: 973-984-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number25MA09331600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: