Provider Demographics
NPI:1568426302
Name:PENNICK, WILLIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:A
Last Name:PENNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1760 EDGEWOOD AVE W
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-7209
Mailing Address - Country:US
Mailing Address - Phone:904-358-8480
Mailing Address - Fax:904-358-8460
Practice Address - Street 1:1760 EDGEWOOD AVE W
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-7209
Practice Address - Country:US
Practice Address - Phone:904-358-8480
Practice Address - Fax:904-358-8460
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME53419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062977400Medicaid
FL05978YMedicare ID - Type Unspecified
FLD21082Medicare UPIN