Provider Demographics
NPI:1093974511
Name:PENISTON, REO MALACHI (MD)
Entity Type:Individual
Prefix:
First Name:REO
Middle Name:MALACHI
Last Name:PENISTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:1296 W BROAD ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-2012
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:352-429-5606
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2021-01-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY264985-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108872000Medicaid