Provider Demographics
NPI:1467687590
Name:PENEDO, ERIC BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:BRIAN
Last Name:PENEDO
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-346-3649
Practice Address - Fax:904-348-5627
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.30762207R00000X
CAA125287207R00000X
FLME124402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01497428OtherRAILROAD MEDICARE
FL015085500Medicaid
FL015085500Medicaid