Basic Information
| Provider Information | |||||||||
| NPI: | 1710059324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVALLARO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 HIDDEN RIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | HONEOYE FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144729378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855821952 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859223846 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 1801241 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.