Provider Demographics
NPI:1407877392
Name:CHARLES PERNICIARO MD PA
Entity Type:Organization
Organization Name:CHARLES PERNICIARO MD PA
Other - Org Name:NEPTUNE BEACH DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER & PHYSICIAN PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:V
Authorized Official - Last Name:PERNICIARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-241-0633
Mailing Address - Street 1:PO BOX 51498
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32240-1498
Mailing Address - Country:US
Mailing Address - Phone:904-246-0908
Mailing Address - Fax:
Practice Address - Street 1:183 LANDRUM LN
Practice Address - Street 2:SUITE 201
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3837
Practice Address - Country:US
Practice Address - Phone:904-241-0633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8489Medicare ID - Type UnspecifiedGROUP NUMBER