Healthcare Provider Details

I. General information

NPI: 1578593786
Provider Name (Legal Business Name): CHARLES R DENNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MEDFORD AVE SUITE E
PATCHOGUE NY
11772-1229
US

IV. Provider business mailing address

PO BOX 465
LAUREL NY
11948-0465
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-4190
  • Fax: 631-687-4198
Mailing address:
  • Phone: 631-687-4190
  • Fax: 631-687-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number126943-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00376701
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: