Provider Demographics
NPI:1215009048
Name:PENN, ESTHER A (MD)
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:A
Last Name:PENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ESTHER
Other - Middle Name:A
Other - Last Name:MAKSYMOVITCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1017 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6608
Mailing Address - Country:US
Mailing Address - Phone:707-546-9800
Mailing Address - Fax:707-546-4112
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:STE 200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-525-6482
Practice Address - Fax:707-573-6918
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82492207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A824920Medicaid
H72888Medicare UPIN
00A824920Medicare ID - Type Unspecified