Provider Demographics
NPI:1154488419
Name:PENN, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:PENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10530 DISCOVERY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-3050
Mailing Address - Country:US
Mailing Address - Phone:702-802-2832
Mailing Address - Fax:
Practice Address - Street 1:55 ARCH ST STE 3A
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1447
Practice Address - Country:US
Practice Address - Phone:330-375-3584
Practice Address - Fax:330-375-6306
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042202207QA0000X
NV15507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0396361Medicaid
A78616Medicare UPIN
PE0462392Medicare ID - Type Unspecified