Provider Demographics
NPI:1346431806
Name:PENHALL, BRENT DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DOUGLAS
Last Name:PENHALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 LANGTREE VILLAGE DR STE 200
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-384-7101
Practice Address - Fax:704-384-7102
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2403256Medicare PIN