Healthcare Provider Details

I. General information

NPI: 1699773705
Provider Name (Legal Business Name): CHARLES L. IHLENFELD II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 SOUTH MENANTIC ROAD
SHELTER ISLAND HEIGHTS NY
11965
US

IV. Provider business mailing address

PO BOX 576
SHELTER ISLAND HEIGHTS NY
11965-0576
US

V. Phone/Fax

Practice location:
  • Phone: 631-278-5127
  • Fax: 631-749-3079
Mailing address:
  • Phone: 631-278-5127
  • Fax: 631-749-3079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number092919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: