Provider Demographics
NPI:1720066475
Name:VINSON, CHARLIE STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:STEPHEN
Last Name:VINSON
Suffix:
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 1:2948 BREEZY RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1509
Mailing Address - Country:US
Mailing Address - Phone:757-496-9065
Mailing Address - Fax:
Practice Address - Street 1:1800 CAMELOT DR
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-491-7337
Practice Address - Fax:757-275-9892
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010137691208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006719899Medicare ID - Type Unspecified