Provider Demographics
NPI:1972557890
Name:PERNICIARO, CHARLES VINCENT (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:VINCENT
Last Name:PERNICIARO
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 1:10406 SEASIDE WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4251
Mailing Address - Country:US
Mailing Address - Phone:904-860-1929
Mailing Address - Fax:
Practice Address - Street 1:10406 SEASIDE WAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4251
Practice Address - Country:US
Practice Address - Phone:904-860-1929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017322207N00000X
MN28877207N00000X
AZ21961207N00000X
TXK6231207N00000X
NC2013-02379207ND0900X
SC36240207ND0900X
FL51624207ND0900X
GA042694207ND0900X
FLME51624207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070014059OtherMEDICARE RR
GA52332476003OtherBCBSGA
FL10287OtherBCBS FL
GA000837075BMedicaid
FLHY024AOtherFL MEDAIACRE PTAN
GA070014191OtherMEDICARE RR
GA07BBSHBOtherMEDICARE
FL10287UMedicare ID - Type UnspecifiedPROVIDER NUMBER
GA000837075BMedicaid