Provider Demographics
NPI:1275627655
Name:PENT, MICHELLE P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:P
Last Name:PENT
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3853 ROSECRANS ST
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-692-8232
Mailing Address - Fax:619-542-4060
Practice Address - Street 1:3853 ROSECRANS ST
Practice Address - Street 2:PHS PROVIDER ENROLLMENT
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-692-8232
Practice Address - Fax:619-542-4060
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-05-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2005-02252084P0800X
CAC551452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50276832Medicaid
I39606Medicare UPIN
344525502Medicare PIN