MEDICARE: CHARLIE STEPHEN VINSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	010137691	VA

General Provider Information

NPI Number	:	1720066475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLIE STEPHEN VINSON M.D.

Provider Business Mailing Address
First Line	:	2948 BREEZY RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1509
Country	:	US
Telephone Number	:	757-496-9065
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 CAMELOT DR
Second Line	:	SUITE 200
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2440
Country	:	US
Telephone Number	:	757-491-7337
Fax Number	:	757-275-9892

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	10/06/2011

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