Provider Demographics
NPI:1588677058
Name:PENTEL, MARY TRINH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:TRINH
Last Name:PENTEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13859
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-3859
Mailing Address - Country:US
Mailing Address - Phone:850-205-6232
Mailing Address - Fax:855-975-0615
Practice Address - Street 1:4727 SUNBEAM RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6107
Practice Address - Country:US
Practice Address - Phone:904-880-0622
Practice Address - Fax:904-880-0623
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76473174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1890Medicare ID - Type UnspecifiedPROVIDER NUMBER
FLG74568Medicare UPIN