Provider Demographics
NPI:1134285430
Name:PENKAVA, JERI L (MD)
Entity Type:Individual
Prefix:DR
First Name:JERI
Middle Name:L
Last Name:PENKAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 OGDEN LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5138
Mailing Address - Country:US
Mailing Address - Phone:210-403-2343
Mailing Address - Fax:210-403-2350
Practice Address - Street 1:84 NE LOOP 410 STE 245
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5802
Practice Address - Country:US
Practice Address - Phone:210-403-2343
Practice Address - Fax:210-403-2350
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4242208000000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121517009Medicaid
TX347259OtherPTAN
TX121517009Medicaid