Healthcare Provider Details

I. General information

NPI: 1720066475
Provider Name (Legal Business Name): CHARLIE STEPHEN VINSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CAMELOT DR SUITE 200
VIRGINIA BEACH VA
23454-2440
US

IV. Provider business mailing address

2948 BREEZY RD
VIRGINIA BEACH VA
23451-1509
US

V. Phone/Fax

Practice location:
  • Phone: 757-491-7337
  • Fax: 757-275-9892
Mailing address:
  • Phone: 757-496-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number010137691
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: