Provider Demographics
NPI:1255315032
Name:SUTTON, CHARLES S (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:SUTTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 CROSSGATE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8868
Mailing Address - Country:US
Mailing Address - Phone:855-500-2635
Mailing Address - Fax:570-207-4351
Practice Address - Street 1:3 W OLIVE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2572
Practice Address - Country:US
Practice Address - Phone:855-500-2635
Practice Address - Fax:570-207-4351
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046702L2085R0202X, 2085R0204X
NHEL088652085R0204X
IN01089579A2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE76189Medicare UPIN