Provider Demographics
NPI:1396837225
Name:PENIX, LAROY PETE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAROY
Middle Name:PETE
Last Name:PENIX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1667 NISKEY LAKE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-6401
Mailing Address - Country:US
Mailing Address - Phone:404-344-3142
Mailing Address - Fax:404-344-9263
Practice Address - Street 1:1100 CLEVELAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3602
Practice Address - Country:US
Practice Address - Phone:404-766-4760
Practice Address - Fax:404-766-4702
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA490802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00886894AMedicaid
GAF29736Medicare UPIN
GA00886894AMedicaid