Provider Demographics
NPI:1225256274
Name:PENNESI, MARK EDWARD (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:PENNESI
Suffix:
Gender:M
Credentials:MD PHD
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Other - Credentials:
Mailing Address - Street 1:2351 NW WESTOVER RD
Mailing Address - Street 2:310
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3779
Mailing Address - Country:US
Mailing Address - Phone:415-676-1721
Mailing Address - Fax:
Practice Address - Street 1:3375 SW TERWILLIGER BLVD
Practice Address - Street 2:CEI
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4146
Practice Address - Country:US
Practice Address - Phone:503-494-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28382207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology