Provider Demographics
NPI:1164463402
Name:VANDESTREEK, PENNY ROBILLARD (DO)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:ROBILLARD
Last Name:VANDESTREEK
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:#100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:ATT: NUCLEAR MEDICINE
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3037
Practice Address - Country:US
Practice Address - Phone:916-781-1292
Practice Address - Fax:916-663-9912
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A6232207UN0903X, 207U00000X, 207UN0902X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear Medicine
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX62320Medicaid
CAP00017739OtherRAILROAD MEDICARE
CA020A62320Medicare PIN
CA00AX62320Medicaid