Provider Demographics
NPI:1285633842
Name:PENUEL, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PENUEL
Suffix:
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 1:1854 SHACKLEFORD CT
Mailing Address - Street 2:SUITE 350
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2954
Mailing Address - Country:US
Mailing Address - Phone:770-688-3801
Mailing Address - Fax:770-237-6148
Practice Address - Street 1:821 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2343
Practice Address - Country:US
Practice Address - Phone:478-452-0524
Practice Address - Fax:478-452-0525
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900983174400000X
GA0489262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00926483DMedicaid
GA048926OtherLICENSE
GA581593676OtherTAX IDENTIFICATION
GAP00991552OtherRR MEDICARE
GAP00991552OtherRR MEDICARE
GA00926483DMedicaid
GA511I300066Medicare PIN
GAP00991552OtherRR MEDICARE