Provider Demographics
NPI:1811940620
Name:PERNICE, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PERNICE
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 1:2106 NEW RD
Mailing Address - Street 2:SUITE D1
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1050
Mailing Address - Country:US
Mailing Address - Phone:609-927-9545
Mailing Address - Fax:609-927-2920
Practice Address - Street 1:2106 NEW RD
Practice Address - Street 2:SUITE D1
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1050
Practice Address - Country:US
Practice Address - Phone:609-927-9545
Practice Address - Fax:609-927-2920
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04100800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0010640OtherUS HEALTHCARE
NJ0100759001OtherAMERIHEALTH
NJ156502908OtherUNITED HEALTHCARE
NJF09371OtherHEALTHNET
NJ2013207Medicaid
NJNJ41008OtherMUTUAL OF OMAHA
NJ080009150Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NJE06191Medicare UPIN
NJ439526Medicare ID - Type UnspecifiedMEDICARE NJ