Healthcare Provider Details

I. General information

NPI: 1710149356
Provider Name (Legal Business Name): CHARLES TIMOTHY FASANYA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-7575
  • Fax: 845-333-1454
Mailing address:
  • Phone: 845-333-1114
  • Fax: 845-333-2645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA08347800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number254698
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: