Provider Demographics
NPI:1952446817
Name:BURTON, CHARLES H JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:BURTON
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 1:1587 PHOENIX BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5540
Mailing Address - Country:US
Mailing Address - Phone:770-994-6806
Mailing Address - Fax:770-994-6807
Practice Address - Street 1:1587 PHOENIX BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5540
Practice Address - Country:US
Practice Address - Phone:770-994-6806
Practice Address - Fax:770-994-6807
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023025174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00385206CMedicaid
GA00385206CMedicaid
GA16BDTWRMedicare PIN