Basic Information
| Provider Information | |||||||||
| NPI: | 1427314160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | ISAACSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ISAACSON | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2111 LAUREL BUSH RD STE H | ||||||||
| Address2: | |||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105693300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10084 REISTERSTOWN RD STE 200B | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211174096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104941369 | ||||||||
| FaxNumber: | 4104942737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2012 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA09651600 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | D88487 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.