Healthcare Provider Details

I. General information

NPI: 1619057338
Provider Name (Legal Business Name): CHARLES LAWRENCE CARLTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007 N SHERIDAN RD APT 20A
CHICAGO IL
60660-3005
US

IV. Provider business mailing address

6007 N SHERIDAN RD APT 20A
CHICAGO IL
60660-3005
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-4977
  • Fax: 773-561-4988
Mailing address:
  • Phone: 773-561-4977
  • Fax: 773-561-4988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: