Provider Demographics
NPI:1558316083
Name:PENTON, BRIAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:PENTON
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 1:1551 BISHOP ST BLDG A STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4692
Mailing Address - Country:US
Mailing Address - Phone:805-548-8585
Mailing Address - Fax:805-548-8589
Practice Address - Street 1:1551 BISHOP ST BLDG A STE 110
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4692
Practice Address - Country:US
Practice Address - Phone:805-548-8585
Practice Address - Fax:805-548-8589
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84188207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A841880Medicaid
CAA84188OtherNHIC- MEDICARE INDV PROVIDER NUMBER
CABV188ZOtherMEDICARE INDV PTAN NUMBER- PALMETTO GBA
CAH95049Medicare UPIN