Provider Demographics
NPI:1205854312
Name:SCARBOROUGH, CHARLES DUNN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DUNN
Last Name:SCARBOROUGH
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 1:31 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2301
Mailing Address - Country:US
Mailing Address - Phone:904-259-2725
Mailing Address - Fax:904-259-2907
Practice Address - Street 1:31 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2301
Practice Address - Country:US
Practice Address - Phone:904-259-2725
Practice Address - Fax:904-259-2907
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 18474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049203500Medicaid
FL049203500Medicaid
FL91733Medicare ID - Type Unspecified
FLD79876Medicare UPIN