Provider Demographics
NPI:1942202783
Name:FENTON, CHARLES FRANCIS III (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FRANCIS
Last Name:FENTON
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1705
Mailing Address - Country:US
Mailing Address - Phone:404-843-0090
Mailing Address - Fax:404-843-1008
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 420
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1705
Practice Address - Country:US
Practice Address - Phone:404-843-0090
Practice Address - Fax:404-843-1008
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000466213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT97570Medicare UPIN
GAGRP71Medicare ID - Type Unspecified