Provider Demographics
NPI:1083692743
Name:BERNICK, CHARLES BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BENJAMIN
Last Name:BERNICK
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 1:888 W BONNEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-0100
Mailing Address - Country:US
Mailing Address - Phone:702-483-6000
Mailing Address - Fax:
Practice Address - Street 1:888 W BONNEVILLE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-0100
Practice Address - Country:US
Practice Address - Phone:702-483-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD609232142084N0400X
NV69782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083692743Medicaid
NVBB0463264OtherDEA
NV100500484Medicaid
NVCS07202OtherSTATE PHARMACY
NVCS07202OtherSTATE PHARMACY
NVBB0463264OtherDEA
NVA37757Medicare UPIN
NVWQBHVMedicare ID - Type UnspecifiedGROUP MEDICARE