Provider Demographics
NPI:1518993575
Name:PENNZA, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PENNZA
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 1:822 KUMHO DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-9297
Mailing Address - Country:US
Mailing Address - Phone:330-576-0500
Mailing Address - Fax:330-576-0467
Practice Address - Street 1:822 KUMHO DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-9297
Practice Address - Country:US
Practice Address - Phone:330-576-0500
Practice Address - Fax:330-576-0467
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042484P207Q00000X
OH35042484208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000141923OtherANTHEM
OH0423616Medicaid
OH0007548749OtherAETNA
OH0423616Medicaid
OH000000141923OtherANTHEM
OHPE0773005Medicare ID - Type Unspecified