Provider Demographics
NPI:1124116942
Name:GELLIDO, CHARLES LAGAYA (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAGAYA
Last Name:GELLIDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 CLIFTON AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3523
Mailing Address - Country:US
Mailing Address - Phone:888-605-3975
Mailing Address - Fax:888-605-3975
Practice Address - Street 1:1005 CLIFTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3523
Practice Address - Country:US
Practice Address - Phone:888-605-3975
Practice Address - Fax:888-605-3975
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0699392084N0400X
NJMA699392084N0600X
NY2302692084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherCOMMERCIAL AND MEDICARE
NY02179353Medicaid
NY02179353Medicaid