Healthcare Provider Details

I. General information

NPI: 1659345353
Provider Name (Legal Business Name): CHARLES M PERRICONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 ZEID BLVD
HENDERSON TX
75652-6070
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-657-7583
  • Fax:
Mailing address:
  • Phone: 903-324-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG8337
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: