Provider Demographics
NPI:1497060487
Name:PERENICH, MARK NICHOLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NICHOLAS
Last Name:PERENICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7702 STILL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2263
Mailing Address - Country:US
Mailing Address - Phone:813-803-0029
Mailing Address - Fax:813-949-8919
Practice Address - Street 1:6536 GUNN HWY.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-3853
Practice Address - Country:US
Practice Address - Phone:813-803-0029
Practice Address - Fax:813-949-8919
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3421207XS0117X
FLOS14036207XS0117X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVJSQKOtherBLUE CROSS
FLOS14036OtherMEDICAL LICENSE
FL103265500Medicaid