Provider Demographics
NPI:1558624411
Name:CAREY S. PENNISTON, DO, PA
Entity Type:Organization
Organization Name:CAREY S. PENNISTON, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-321-2673
Mailing Address - Street 1:10534 GARLAND RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2637
Mailing Address - Country:US
Mailing Address - Phone:214-321-2673
Mailing Address - Fax:
Practice Address - Street 1:10534 GARLAND RD
Practice Address - Street 2:SUITE B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-2637
Practice Address - Country:US
Practice Address - Phone:214-321-2673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty