Provider Demographics
NPI:1407440001
Name:DAVID PENNER MD PLLC
Entity Type:Organization
Organization Name:DAVID PENNER MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-539-1736
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0023
Mailing Address - Country:US
Mailing Address - Phone:360-539-1736
Mailing Address - Fax:360-350-5610
Practice Address - Street 1:1801 W BAY DR NW STE 104
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4310
Practice Address - Country:US
Practice Address - Phone:360-539-1736
Practice Address - Fax:360-350-5610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2149000Medicaid