Healthcare Provider Details

I. General information

NPI: 1043479926
Provider Name (Legal Business Name): CHARLESSE PONDT HUANNOU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 MORRIS AVE 2ND FLOOR
SPRINGFIELD NJ
07081-1151
US

IV. Provider business mailing address

385 MORRIS AVE STE 100
SPRINGFIELD NJ
07081-1100
US

V. Phone/Fax

Practice location:
  • Phone: 973-379-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number25MA09494200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: