Basic Information
| Provider Information | |||||||||
| NPI: | 1659332864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROPPER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2016 BRONXDALE AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104623388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189181356 | ||||||||
| FaxNumber: | 7189181301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2016 BRONXDALE AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104623388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189181356 | ||||||||
| FaxNumber: | 7189181301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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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 | 207N00000X | 175302 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 01355884 | 05 | NY | MEDICAID |