Healthcare Provider Details

I. General information

NPI: 1255315032
Provider Name (Legal Business Name): CHARLES S SUTTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 W OLIVE ST SUITE 201
SCRANTON PA
18508-2572
US

IV. Provider business mailing address

301 CROSSGATE DR
SOUTH ABINGTON TOWNSHIP PA
18411-8868
US

V. Phone/Fax

Practice location:
  • Phone: 855-500-2635
  • Fax: 570-207-4351
Mailing address:
  • Phone: 855-500-2635
  • Fax: 570-207-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD046702L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberEL08865
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD046702L
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number01089579A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: