Healthcare Provider Details

I. General information

NPI: 1558349886
Provider Name (Legal Business Name): CHARLES S DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 LEGRANDE AVE
CHARLOTTE COURT HOUSE VA
23923-3747
US

IV. Provider business mailing address

HIGHWAY 15 SOUTH
NEW CANTON VA
23123
US

V. Phone/Fax

Practice location:
  • Phone: 434-542-5560
  • Fax: 434-542-5745
Mailing address:
  • Phone: 434-581-3271
  • Fax: 434-581-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0101025148
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: