Provider Demographics
NPI:1124254917
Name:MIKELL, CHARLES BAZEMORE III (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BAZEMORE
Last Name:MIKELL
Suffix:III
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:HSC T12
Mailing Address - Street 2:ROOM 080
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8122
Mailing Address - Country:US
Mailing Address - Phone:631-444-1116
Mailing Address - Fax:
Practice Address - Street 1:HSC T12
Practice Address - Street 2:ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8122
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-07
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP008207T00000X
NY273606207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program