=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215914627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES T MARSTON JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2005
-----------------------------------------------------
Last Update Date | 01/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 NORTH MAIN STREET
-----------------------------------------------------
City | KENANSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28349-0278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-963-9066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8712 PLANTATION DR PO BOX 4429
-----------------------------------------------------
City | EMERALD ISLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28594-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-963-9066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 23862
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------