Provider Demographics
NPI:1417960881
Name:PENN, GORDON J (OD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:J
Last Name:PENN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:GORDON
Other - Middle Name:J
Other - Last Name:PENN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:8500 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6600
Mailing Address - Country:US
Mailing Address - Phone:321-259-4393
Mailing Address - Fax:321-242-6132
Practice Address - Street 1:8500 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-6600
Practice Address - Country:US
Practice Address - Phone:321-259-4393
Practice Address - Fax:321-242-6132
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2710152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20466Medicare ID - Type UnspecifiedMEDICARE #
FLU21130Medicare UPIN