Provider Demographics
NPI:1326054321
Name:HORTON, CHARLES EDWIN JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWIN
Last Name:HORTON
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 741593
Mailing Address - Street 2:CHILDRENS SURGICAL SPECIALTY GROUP INC
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1593
Mailing Address - Country:US
Mailing Address - Phone:757-668-7878
Mailing Address - Fax:757-668-7883
Practice Address - Street 1:601 CHILDRENS LANE
Practice Address - Street 2:CHILDRENS SURGICAL SPECIALTY GROUP INC
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507
Practice Address - Country:US
Practice Address - Phone:757-668-7878
Practice Address - Fax:757-668-7883
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-12-10
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Provider Licenses
StateLicense IDTaxonomies
VA01010452462088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA311610834OtherNC HEALTH CHOICE
VA4131324OtherAETNA
VA910715OtherALLIANCE/MDIPA
VA007502371Medicaid
VA3116108340005EOtherCIGNA
VA8905439OtherNORTH CAROLINA MEDICAID
VA15507OtherOPTIMA/SENTARA HEALTH
VA910715OtherMAMSI/OPTIMUM CHOICE
VT324839OtherANTHEM BCBS
VT324839OtherANTHEM BCBS
VA15507OtherOPTIMA/SENTARA HEALTH