Provider Demographics
NPI:1265492748
Name:PENNE-CASANOVA, ROBERTO A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:A
Last Name:PENNE-CASANOVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059
Mailing Address - Country:US
Mailing Address - Phone:502-386-9415
Mailing Address - Fax:502-899-6108
Practice Address - Street 1:3991 DUTCHMANS LN
Practice Address - Street 2:MEDICAL PLAZA II STE G03
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4700
Practice Address - Country:US
Practice Address - Phone:502-899-6100
Practice Address - Fax:502-899-6108
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY370742083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00022895OtherRAILROAD MEDICARE
KY64048564Medicaid
KY000000235989OtherANTHEM BLUE CROSS BLUE SHIELD
KY1170390OtherPASSPORT HEALTH PLAN
KY2440625000OtherPASSPORT ADVANTAGE
IN200386450AMedicaid
KY000000235989OtherANTHEM BLUE CROSS BLUE SHIELD
IN200386450AMedicaid