Provider Demographics
NPI:1508841123
Name:PENN, JOSEPH VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:VINCENT
Last Name:PENN
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 1:200 RIVER POINTE DRIVE UTMB CMC
Mailing Address - Street 2:SUITE #200
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304
Mailing Address - Country:US
Mailing Address - Phone:936-494-4170
Mailing Address - Fax:936-494-4195
Practice Address - Street 1:200 RIVER POINTE DRIVE UTMB CMC
Practice Address - Street 2:SUITE #200
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304
Practice Address - Country:US
Practice Address - Phone:936-494-4170
Practice Address - Fax:936-494-4195
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD088492084F0202X, 2084P0800X, 2084P0804X
TXK70812084P0800X, 2084F0202X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7007282Medicaid
G96204Medicare UPIN
007007282Medicare ID - Type Unspecified