Provider Demographics
NPI:1922002963
Name:FAYTON, CHARLES EARL SR (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EARL
Last Name:FAYTON
Suffix:SR
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 1:6477 COLLEGE PARK SQ
Mailing Address - Street 2:STE 118
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3611
Mailing Address - Country:US
Mailing Address - Phone:757-420-6218
Mailing Address - Fax:757-420-0487
Practice Address - Street 1:6477 COLLEGE PARK SQ
Practice Address - Street 2:STE 118
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3611
Practice Address - Country:US
Practice Address - Phone:757-420-6218
Practice Address - Fax:757-420-0487
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033992208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006737358Medicaid
VA006737358Medicaid