Basic Information
| Provider Information | |||||||||
| NPI: | 1659345353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRICONE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 105 ZEID BLVD | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756526070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036577583 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G8337 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 130797705 | 05 | TX | MEDICAID | 75-2616977-017 | 01 | TX | TRICARE | OTHER | 75-2616977-043 | 01 | TX | TRICARE | OTHER | 75-2616977-066 | 01 | TX | TRICARE | OTHER | 75-2616977-015 | 01 | TX | TRICARE | OTHER | 75-1976930-005 | 01 | TX | TRICARE | OTHER | 130797708 | 05 | TX | MEDICAID | P01754641 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 8GF477 | 01 | TX | BCBS | OTHER |