Provider Demographics
NPI:1720067747
Name:STANISLAV, CHARLES A (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:STANISLAV
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 1:34435 KING STREET ROW STE 1
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-4787
Mailing Address - Country:US
Mailing Address - Phone:302-644-1300
Mailing Address - Fax:302-644-1086
Practice Address - Street 1:34435 KING STREET ROW
Practice Address - Street 2:SUITE 1
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4787
Practice Address - Country:US
Practice Address - Phone:302-644-1300
Practice Address - Fax:302-644-1086
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005349207R00000X
FLC100005349207QA0505X
DEC100005349207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG00405Medicare UPIN
DE000Y97A05Medicare PIN