Provider Demographics
NPI:1598064909
Name:PERNULA, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:PERNULA
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 1:5840 W. CRAIG RD.
Mailing Address - Street 2:STE. 120 PMB# 254
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2562
Mailing Address - Country:US
Mailing Address - Phone:702-724-2020
Mailing Address - Fax:702-724-2800
Practice Address - Street 1:5871 W. CRAIG RD.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2575
Practice Address - Country:US
Practice Address - Phone:702-724-2020
Practice Address - Fax:702-724-2800
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15879207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1598064909Medicaid