MEDICARE: CHARLES V PERNICIARO, M.D., P.C., D/B/A BRUNSWICK DERMATOLOGY CLINIC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DA7309	OTHER	GA	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1497771869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES V PERNICIARO, M.D., P.C., D/B/A BRUNSWICK DERMATOLOGY CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 51498
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32240-1498
Country	:	US
Telephone Number	:	904-241-0633
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
Name	:	DR. CHARLES VINCENT PERNICIARO
Credential	:	MD
Telephone Number	:	904-241-0633

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	12/05/2014

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