Provider Demographics
NPI:1558540526
Name:PENNY R. VANDESTREEK DO, INC.
Entity Type:Organization
Organization Name:PENNY R. VANDESTREEK DO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDESTREEK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:916-781-1292
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-7328
Mailing Address - Country:US
Mailing Address - Phone:916-781-1292
Mailing Address - Fax:916-663-9912
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:ATT NUCLEAR MEDICINE
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3037
Practice Address - Country:US
Practice Address - Phone:916-781-1292
Practice Address - Fax:916-663-9912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6232207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX62320Medicaid
P00017739OtherRAILROAD MEDICARE
P00017739OtherRAILROAD MEDICARE
CA00AX62320Medicaid