Provider Demographics
NPI:1508048893
Name:JAIME PENIX MD PA
Entity Type:Organization
Organization Name:JAIME PENIX MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:PENIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-383-1245
Mailing Address - Street 1:3801 N HIGHWAY 19A
Mailing Address - Street 2:STE 400
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2228
Mailing Address - Country:US
Mailing Address - Phone:352-383-1245
Mailing Address - Fax:
Practice Address - Street 1:3801 N HIGHWAY 19A
Practice Address - Street 2:STE 400
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2228
Practice Address - Country:US
Practice Address - Phone:352-383-1245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96543207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI61949Medicare UPIN
FLAH821Medicare PIN