Provider Demographics
NPI:1497729727
Name:FLACK, CHARLES EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:FLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1300 SAWGRASS CORPORATE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2823
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-527-5510
Practice Address - Street 1:10301 HAGEN RANCH RD
Practice Address - Street 2:SUITE C130
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437
Practice Address - Country:US
Practice Address - Phone:561-736-7313
Practice Address - Fax:561-736-2309
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME599372088P0231X
KYTP1032088P0231X
VA01012731762088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL204200OtherAMERIGROUP
FL5962OtherNHP
FL054273300Medicaid
FL103690OtherAVMED
FL12475OtherBCBS
FL1755943OtherCIGNA
FL26943OtherSTAYWELL
FL4611456OtherAETNA NON-HMO
FL2032607OtherAETNA HMO
FL26943OtherWELLCARE