Healthcare Provider Details

I. General information

NPI: 1093753329
Provider Name (Legal Business Name): EDWARD ANTHONY OVERTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 W ARBORS DR STE 115
CHARLOTTE NC
28262-2639
US

IV. Provider business mailing address

PO BOX 480328
CHARLOTTE NC
28269-5338
US

V. Phone/Fax

Practice location:
  • Phone: 704-817-6676
  • Fax:
Mailing address:
  • Phone: 215-669-9668
  • Fax: 704-864-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS-010979L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number1146
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number53011
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number200400934
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: