Provider Demographics
NPI:1396709176
Name:DAVANT, CHARLES III (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:DAVANT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:321 MULBERRY ST SW
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5720
Mailing Address - Country:US
Mailing Address - Phone:828-757-5965
Mailing Address - Fax:828-757-5104
Practice Address - Street 1:8439 VALLEY BLVD.
Practice Address - Street 2:
Practice Address - City:BLOWING ROCK
Practice Address - State:NC
Practice Address - Zip Code:28605-9052
Practice Address - Country:US
Practice Address - Phone:828-295-3116
Practice Address - Fax:828-295-4388
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17944207Q00000X
VA0101023843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927131Medicaid
NC8927131Medicaid
NCNCP834F105Medicare PIN
NC8927131Medicaid