Healthcare Provider Details

I. General information

NPI: 1972557890
Provider Name (Legal Business Name): CHARLES VINCENT PERNICIARO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10406 SEASIDE WAY
TAMPA FL
33615-4251
US

IV. Provider business mailing address

10406 SEASIDE WAY
TAMPA FL
33615-4251
US

V. Phone/Fax

Practice location:
  • Phone: 904-860-1929
  • Fax:
Mailing address:
  • Phone: 904-860-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number017322
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number28877
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number21961
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberK6231
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2013-02379
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number36240
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number51624
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number042694
License Number StateGA
# 9
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME51624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: