Provider Demographics
NPI:1598749293
Name:PENNOCK, GREGORY K (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:K
Last Name:PENNOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13925
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4030
Mailing Address - Country:US
Mailing Address - Phone:904-389-4105
Mailing Address - Fax:904-202-7377
Practice Address - Street 1:1235 SAN MARCO BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8554
Practice Address - Country:US
Practice Address - Phone:904-202-7300
Practice Address - Fax:904-202-7377
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90972207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270909100Medicaid
FL50514YMedicare PIN
FL270909100Medicaid
FL50514ZMedicare PIN
NCNCH903AMedicare PIN
FL50514ZMedicare PIN
FL270909100Medicaid