Provider Demographics
NPI:1528070083
Name:KORROL, CHARLES REUBEN (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:REUBEN
Last Name:KORROL
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:775 PARK AVE
Mailing Address - Street 2:SUITE 200-9
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3976
Mailing Address - Country:US
Mailing Address - Phone:631-549-3888
Mailing Address - Fax:631-549-0243
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:SUITE 200-9
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3976
Practice Address - Country:US
Practice Address - Phone:631-549-3888
Practice Address - Fax:631-549-0243
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2010-04-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0956612084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00625470Medicaid
B14159Medicare UPIN
NY382591Medicare PIN