Provider Demographics
NPI:1609210129
Name:STONEBURNER, CHARLES GRESHAM ROSE JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GRESHAM ROSE
Last Name:STONEBURNER
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 1:1055 SAXON BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8468
Practice Address - Country:US
Practice Address - Phone:386-917-5526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2023-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS00992085R0202X
KY574482085R0202X
FLME1209972085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology