Basic Information
Provider Information | |||||||||
NPI: | 1255336715 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DINERSTEIN | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 300 | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | PA | ||||||||
PostalCode: | 170420300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172707780 | ||||||||
FaxNumber: | 7172749746 | ||||||||
Practice Location | |||||||||
Address1: | 4TH & WALNUT STREETS | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | LEBANON | ||||||||
State: | PA | ||||||||
PostalCode: | 170426123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172703751 | ||||||||
FaxNumber: | 2702703754 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 12/03/2014 | ||||||||
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 | 2086S0129X | MA048088 | NJ | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 102760804001 | 05 | PA |   | MEDICAID | 3967000 | 05 | NJ |   | MEDICAID |