=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144217282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES WILLIAM DEATON JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2005
-----------------------------------------------------
Last Update Date | 12/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 S UNIVERSITY AVE STE 600
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-664-3914
-----------------------------------------------------
Fax | 501-664-5246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 S UNIVERSITY AVE STE 101
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-5302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-664-3914
-----------------------------------------------------
Fax | 501-664-5246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | R3975
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | R3975
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------