Provider Demographics
NPI:1184661084
Name:PENZIEN, DONALD (PHD)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:PENZIEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5808
Practice Address - Fax:601-815-4710
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28-387103TC0700X
NC5203103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114323Medicaid
MS680010494OtherRAILROAD MEDICARE
MS302I685830Medicare PIN
MS512I680012Medicare PIN
MS00114323Medicaid
MS680010494OtherRAILROAD MEDICARE