Provider Demographics
NPI:1497775688
Name:SWANSON, CHARLIE L JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:L
Last Name:SWANSON
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 1:2900 TYLER RD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-6374
Mailing Address - Country:US
Mailing Address - Phone:540-731-7314
Mailing Address - Fax:540-731-7377
Practice Address - Street 1:2900 TYLER RD
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6374
Practice Address - Country:US
Practice Address - Phone:540-731-7314
Practice Address - Fax:540-731-7377
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL247182084P0800X
VA2084P0800X2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014CMMedicaid
NC2062309AOtherMEDICARE
NC144J0OtherBCBS