Provider Demographics
NPI:1174629448
Name:LOVELL, CHARLES FREDERICK JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:LOVELL
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 1:142 W. YORK STREET
Mailing Address - Street 2:SUITE 905
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2015
Mailing Address - Country:US
Mailing Address - Phone:757-623-3038
Mailing Address - Fax:757-623-0101
Practice Address - Street 1:142 W. YORK STREET
Practice Address - Street 2:SUITE 905
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2015
Practice Address - Country:US
Practice Address - Phone:757-623-3038
Practice Address - Fax:757-623-0101
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006354OtherANTHEM BLUE CROSS BLUE SH
VA006074936Medicaid
111936953OtherMEDICARE PTAN
VA006354OtherANTHEM BLUE CROSS BLUE SH