Provider Demographics
NPI:1073598132
Name:PENN, GERALD MELVILLE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:MELVILLE
Last Name:PENN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SHAWAN FALLS DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-2100
Mailing Address - Country:US
Mailing Address - Phone:614-764-1711
Mailing Address - Fax:614-889-2652
Practice Address - Street 1:650 SHAWAN FALLS DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2100
Practice Address - Country:US
Practice Address - Phone:614-764-1711
Practice Address - Fax:614-889-2652
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35027499207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1351OtherRR MEDICARE GRP ID
OH9932361Medicare PIN
OHE95973Medicare UPIN
OH0760008Medicare PIN