Provider Demographics
NPI:1679586895
Name:SIMONTON, CHARLES ALISON III (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALISON
Last Name:SIMONTON
Suffix:III
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:PO BOX 60122
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0122
Mailing Address - Country:US
Mailing Address - Phone:704-373-0212
Mailing Address - Fax:704-373-1216
Practice Address - Street 1:1001 BLYTHE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5863
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:704-373-1216
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28346207R00000X, 207RC0000X, 207RI0011X
SC14424207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN28346Medicaid
NC76354OtherBCBS
P00205957OtherRAILROAD MEDICARE
NC8976354Medicaid
NC8976354Medicaid
NC76354OtherBCBS