Healthcare Provider Details

I. General information

NPI: 1811998982
Provider Name (Legal Business Name): NELSON CHARLIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SE 10TH AVE SUITE 305
FORT LAUDERDALE FL
33316-2901
US

IV. Provider business mailing address

1800 SE 10TH AVE SUITE 305
FORT LAUDERDALE FL
33316-2901
US

V. Phone/Fax

Practice location:
  • Phone: 954-467-4100
  • Fax: 954-467-4080
Mailing address:
  • Phone: 954-467-4100
  • Fax: 954-467-4080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME85619
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME85619
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: