Provider Demographics
NPI:1386675643
Name:MOUTON, CHARLES P (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
Last Name:MOUTON
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 1:1005 DR DB TODD JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3501
Mailing Address - Country:US
Mailing Address - Phone:615-327-5520
Mailing Address - Fax:
Practice Address - Street 1:1005 DR DB TODD JR BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3501
Practice Address - Country:US
Practice Address - Phone:615-327-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD18521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010170478Medicaid
MD405515200Medicaid
DC035952100Medicaid
014743H13Medicare PIN
E36921Medicare UPIN