Provider Demographics
NPI:1528594942
Name:PERNISCO, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PERNISCO
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 1:687 FINLEY CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1267
Mailing Address - Country:US
Mailing Address - Phone:503-560-6893
Mailing Address - Fax:
Practice Address - Street 1:6451 BRENTWOOD STAIR RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-3200
Practice Address - Country:US
Practice Address - Phone:817-507-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS2462207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program