Basic Information
| Provider Information | |||||||||
| NPI: | 1346297397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRAKE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | GEORGE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 W 168TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123055098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 161 FORT WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123055098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | D59039 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 287243 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 401519300 | 05 | MD | MEDICAID |