1235145228 NPI number — CHARLES MIEZEJESKI PH.D.

Table of content: CHARLES MIEZEJESKI PH.D. (NPI 1235145228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235145228 NPI number — CHARLES MIEZEJESKI PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIEZEJESKI
Provider First Name:
CHARLES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235145228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
556 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10302-2510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-744-5941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1745 BROADWAY
Provider Second Line Business Practice Location Address:
17 FL
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10019-4640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-851-8100
Provider Business Practice Location Address Fax Number:
212-537-0102
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  6368 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01676984 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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