Provider Demographics
NPI:1306818711
Name:BLANTON, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:BLANTON
Suffix:
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1080
Mailing Address - Fax:704-384-1122
Practice Address - Street 1:1401 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5402
Practice Address - Country:US
Practice Address - Phone:704-384-1080
Practice Address - Fax:704-384-1122
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-00513208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00516Medicaid
NC8916237Medicaid
NC2218232AMedicare ID - Type Unspecified
SCN00516Medicaid