Provider Demographics
NPI:1528027828
Name:BURTON, CHARLES RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RUSSELL
Last Name:BURTON
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 1:819 W CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3349
Mailing Address - Country:US
Mailing Address - Phone:501-778-8264
Mailing Address - Fax:501-778-7360
Practice Address - Street 1:819 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3349
Practice Address - Country:US
Practice Address - Phone:501-778-8264
Practice Address - Fax:501-778-7360
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105298001Medicaid
AR5473014OtherAETNA
AR11140000OtherQUALCHOICE
AR11140000OtherQUALCHOICE
ARE16737Medicare UPIN
AR080059916Medicare PIN