Provider Demographics
NPI:1053378109
Name:NILES, CHARLES R (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:NILES
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 1:6333 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5800
Mailing Address - Country:US
Mailing Address - Phone:716-632-3545
Mailing Address - Fax:716-632-6368
Practice Address - Street 1:6333 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5800
Practice Address - Country:US
Practice Address - Phone:716-632-3545
Practice Address - Fax:716-632-6368
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158661207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01021452Medicaid
NY01021452Medicaid
NYB20523Medicare ID - Type Unspecified