Provider Demographics
NPI:1356444855
Name:PENNISI, ALFRED JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:JOHN
Last Name:PENNISI
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 1:10833 LE CONTE AVE
Mailing Address - Street 2:12-441 MDCC
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-9346
Mailing Address - Fax:310-206-4855
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:12-441 MDCC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-9346
Practice Address - Fax:310-206-4855
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21570208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053510Medicaid
CA00G215700Medicaid
CA00G215700Medicaid
CAGR0053510Medicaid
CAW11810Medicare ID - Type UnspecifiedGROUP