Provider Demographics
NPI:1144217282
Name:DEATON, CHARLES WILLIAM JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:DEATON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-664-3914
Mailing Address - Fax:501-664-5246
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:STE 600
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-664-3914
Practice Address - Fax:501-664-5246
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR39752085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115746001Medicaid
AR115746001Medicaid
AR52925Medicare ID - Type Unspecified