Provider Demographics
NPI:1154374734
Name:CHARLSON, MARK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:CHARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:192 TILLEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4440
Mailing Address - Country:US
Mailing Address - Phone:802-847-2663
Mailing Address - Fax:802-847-3797
Practice Address - Street 1:192 TILLEY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4440
Practice Address - Country:US
Practice Address - Phone:802-847-2663
Practice Address - Fax:802-847-3797
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0011585207XX0004X, 207X00000X
NC200400468207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015272Medicaid
VT1015272Medicaid