Provider Demographics
NPI:1023211257
Name:DR. MICHAEL R. PENNEY OPTOMETRIST PC
Entity Type:Organization
Organization Name:DR. MICHAEL R. PENNEY OPTOMETRIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-785-1442
Mailing Address - Street 1:3061 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8658
Mailing Address - Country:US
Mailing Address - Phone:573-785-1442
Mailing Address - Fax:573-776-6024
Practice Address - Street 1:3061 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8658
Practice Address - Country:US
Practice Address - Phone:573-785-1442
Practice Address - Fax:573-776-6024
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. MICHAEL R PENNEY OPTOMETRIST PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-06
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02754152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312422207Medicaid
MO312422207Medicaid
MOT83253Medicare UPIN