Provider Demographics
NPI:1205820594
Name:PERNIKOFF, DAVID JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOEL
Last Name:PERNIKOFF
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 1:2865 NETHERTON DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-4674
Mailing Address - Country:US
Mailing Address - Phone:314-653-1600
Mailing Address - Fax:314-355-5716
Practice Address - Street 1:2865 NETHERTON DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-4674
Practice Address - Country:US
Practice Address - Phone:314-653-1600
Practice Address - Fax:314-355-5716
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201878303Medicaid
MO000006157Medicare ID - Type Unspecified
MO201878303Medicaid