Provider Demographics
NPI:1699773705
Name:IHLENFELD, CHARLES L II (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:IHLENFELD
Suffix:II
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:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:SHELTER ISLAND HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11965-0576
Mailing Address - Country:US
Mailing Address - Phone:631-278-5127
Mailing Address - Fax:631-749-3079
Practice Address - Street 1:14 SOUTH MENANTIC ROAD
Practice Address - Street 2:
Practice Address - City:SHELTER ISLAND HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11965
Practice Address - Country:US
Practice Address - Phone:631-278-5127
Practice Address - Fax:631-749-3079
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0929192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM00150376 Y0608Medicaid
CI09233010Medicare ID - Type Unspecified
NYM00150376 Y0608Medicaid