Healthcare Provider Details

I. General information

NPI: 1174629448
Provider Name (Legal Business Name): CHARLES FREDERICK LOVELL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 W. YORK STREET SUITE 905
NORFOLK VA
23510-2015
US

IV. Provider business mailing address

142 W. YORK STREET SUITE 905
NORFOLK VA
23510-2015
US

V. Phone/Fax

Practice location:
  • Phone: 757-623-3038
  • Fax: 757-623-0101
Mailing address:
  • Phone: 757-623-3038
  • Fax: 757-623-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101027439
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: