MEDICARE: MR. CHARLES DAVANT III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	17944	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396709176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES DAVANT III MD

Provider Business Mailing Address
First Line	:	321 MULBERRY ST SW
Second Line	:	MEDICAL STAFF SERVICES
City	:	LENOIR
State	:	NC
Zip	:	28645-5720
Country	:	US
Telephone Number	:	828-757-5965
Fax Number	:	828-757-5104

Provider Business Practice Location Address
First Line	:	8439 VALLEY BLVD.
Second Line	:
City	:	BLOWING ROCK
State	:	NC
Zip	:	28605-9052
Country	:	US
Telephone Number	:	828-295-3116
Fax Number	:	828-295-4388

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	03/17/2021

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