=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598754509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYDIA CHARLES MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2005
-----------------------------------------------------
Last Update Date | 11/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1680 ROUTE 23 SUITE 350
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-7501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-521-9700
-----------------------------------------------------
Fax | 973-521-9707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1680 ROUTE 23 SUITE 350
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-7501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-521-9700
-----------------------------------------------------
Fax | 973-521-9707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | MA06235800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------