Provider Demographics
NPI:1467270009
Name:PERENICH, SAMUEL
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:PERENICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 W BEACH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2953
Mailing Address - Country:US
Mailing Address - Phone:563-676-1188
Mailing Address - Fax:
Practice Address - Street 1:7547 JACQUE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7163
Practice Address - Country:US
Practice Address - Phone:727-862-8561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119155207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9119155OtherSTATE LICENSE