Healthcare Provider Details

I. General information

NPI: 1497060487
Provider Name (Legal Business Name): MARK NICHOLAS PERENICH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 03/16/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6536 GUNN HWY.
TAMPA FL
33625-3853
US

IV. Provider business mailing address

7702 STILL PARK CIR
ODESSA FL
33556-2263
US

V. Phone/Fax

Practice location:
  • Phone: 813-803-0029
  • Fax: 813-949-8919
Mailing address:
  • Phone: 813-803-0029
  • Fax: 813-949-8919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberQ3421
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberOS14036
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: