Provider Demographics
NPI:1487653341
Name:PENNISI, VINCENT P (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:P
Last Name:PENNISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1090
Mailing Address - Country:US
Mailing Address - Phone:209-334-1800
Mailing Address - Fax:209-334-1430
Practice Address - Street 1:1617 N CALIFORNIA ST.
Practice Address - Street 2:SUITE 2-A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-466-8546
Practice Address - Fax:209-466-3335
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45259174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G452590Medicaid
CA1386636165OtherGROUP NPI
CA00G452590Medicaid
CA1386636165OtherGROUP NPI
CAA49958Medicare UPIN