Provider Demographics
NPI:1558400788
Name:PENNELLA, RAFFAELE (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFFAELE
Middle Name:
Last Name:PENNELLA
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 1:3808 S GREYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-889-3332
Mailing Address - Fax:417-881-1410
Practice Address - Street 1:3808 S GREYSTONE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-889-3332
Practice Address - Fax:417-881-1410
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110288207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156123001Medicaid
MO208269902Medicaid
AR81292OtherARK BLUE SHIELD
MO31905OtherMO BLUE SHIELD
AR81292OtherARK BLUE SHIELD
MO208269902Medicaid
MO117013268Medicare PIN