Basic Information
Provider Information | |||||||||
NPI: | 1114918778 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRADIEU | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRADIEU | ||||||||
OtherFirstName: | CHARLES | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | .M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1743 ATHERTON AVE | ||||||||
Address2: | 1743 ATHERTON AVE | ||||||||
City: | ELMONT | ||||||||
State: | NY | ||||||||
PostalCode: | 110031744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5164243216 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 S BLISS AVE | ||||||||
Address2: | 100 SOUTH BLISS AVE | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744642512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184583100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2005 | ||||||||
LastUpdateDate: | 01/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 15061 | PR | Y |   | Other Service Providers | Specialist |   |
No ID Information.