Provider Demographics
NPI:1497779391
Name:GRAYSON- MATHIS, CHARLOTTE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ELIZABETH
Last Name:GRAYSON- MATHIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4742 LONGCOURT DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-7194
Mailing Address - Country:US
Mailing Address - Phone:678-427-0734
Mailing Address - Fax:
Practice Address - Street 1:101 YORKTOWN DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-801-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALL057811207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine