Provider Demographics
NPI:1902075997
Name:CHARLES J. LANCELOTTA JR., M.D., P.A.
Entity Type:Organization
Organization Name:CHARLES J. LANCELOTTA JR., M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LANCELOTTA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:410-715-2533
Mailing Address - Street 1:11085 LITTLE PATUXENT PKWY
Mailing Address - Street 2:SUITE LL-007
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2983
Mailing Address - Country:US
Mailing Address - Phone:410-715-2533
Mailing Address - Fax:410-715-2536
Practice Address - Street 1:11055 LITTLE PATUXENT PKWY
Practice Address - Street 2:SUITE L7
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2896
Practice Address - Country:US
Practice Address - Phone:410-715-2533
Practice Address - Fax:410-715-2536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0009071174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD016NMedicare PIN
MDC49367Medicare UPIN
DCG01734Medicare PIN