Basic Information
| Provider Information | |||||||||
| NPI: | 1407930092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | LUKAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHARLES | ||||||||
| OtherFirstName: | LUKAS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 52788 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379502788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657668800 | ||||||||
| FaxNumber: | 8657668874 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E 77TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100211850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124342685 | ||||||||
| FaxNumber: | 2124345523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 12/30/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 150249 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02269607 | 05 | NY | MEDICAID | 0542407 | 05 | NJ | MEDICAID | 689S31 | 01 | NY | EMPIRE BCBS | OTHER |