MEDICARE: CHARLES PERNICIARO MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician

General Provider Information

NPI Number	:	1407877392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES PERNICIARO MD PA

Provider Business Mailing Address
First Line	:	PO BOX 51498
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32240-1498
Country	:	US
Telephone Number	:	904-246-0908
Fax Number	:

Provider Business Practice Location Address
First Line	:	183 LANDRUM LN
Second Line	:	SUITE 201
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-3837
Country	:	US
Telephone Number	:	904-241-0633
Fax Number	:

Authorized Official
Title or Position	:	OWNER & PHYSICIAN PROVIDER
Name	:	DR. CHARLES V. PERNICIARO
Credential	:	M.D.
Telephone Number	:	904-241-0633

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	12/05/2014

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