Provider Demographics
NPI:1588665947
Name:PENROD, CAREY (DO)
Entity Type:Individual
Prefix:
First Name:CAREY
Middle Name:
Last Name:PENROD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 LIPPINCOTT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-0598
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:1364 ROUTE 72 W
Practice Address - Street 2:SUITE 5
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2485
Practice Address - Country:US
Practice Address - Phone:609-978-0778
Practice Address - Fax:609-978-1377
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06078900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6583806Medicaid
NJ6583806Medicaid
G19619Medicare UPIN