Provider Demographics
NPI:1366440513
Name:PENTA, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:PENTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:301 S 7TH AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1410
Mailing Address - Country:US
Mailing Address - Phone:610-376-6990
Mailing Address - Fax:610-376-6458
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1410
Practice Address - Country:US
Practice Address - Phone:610-376-6990
Practice Address - Fax:610-376-6458
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012179E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006080480001Medicaid
88761OtherAETNA
0019754000OtherINDEPENDENCE BLUE CROSS
01161501OtherCAPITAL BLUE CROSS
174356OtherMEDPLUS
076111OtherHIGHMARK BLUE SHIELD
1505952OtherGATEWAY
20008539OtherAMERIHEALTH MERCY
P00309195OtherRAILROAD MEDICARE
1505952OtherGATEWAY
C29125Medicare UPIN