Provider Demographics
NPI:1265499008
Name:PENEPENT, PHILIP A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:PENEPENT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5196 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:BOWMANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14026-1038
Mailing Address - Country:US
Mailing Address - Phone:716-681-1895
Mailing Address - Fax:716-681-5439
Practice Address - Street 1:5196 GENESEE ST
Practice Address - Street 2:
Practice Address - City:BOWMANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14026-1038
Practice Address - Country:US
Practice Address - Phone:716-681-1895
Practice Address - Fax:716-681-5439
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00751193Medicaid
NYB71721Medicare UPIN
NY00751193Medicaid