Provider Demographics
NPI:1811998982
Name:CHARLIE, NELSON (MD)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:
Last Name:CHARLIE
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 1:1800 SE 10TH AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2901
Mailing Address - Country:US
Mailing Address - Phone:954-467-4100
Mailing Address - Fax:954-467-4080
Practice Address - Street 1:1800 SE 10TH AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2901
Practice Address - Country:US
Practice Address - Phone:954-467-4100
Practice Address - Fax:954-467-4080
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85619207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH18810Medicare UPIN
FLK6017Medicare ID - Type Unspecified
FLK6017Medicare PIN