Provider Demographics
NPI:1598944845
Name:PENEGAR, JOEL L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:L
Last Name:PENEGAR
Suffix:
Gender:M
Credentials:OD
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 207261
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7261
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:1007 SKYWAY DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3050
Practice Address - Country:US
Practice Address - Phone:704-289-1547
Practice Address - Fax:704-291-9441
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09703OtherBLCROSS
NC8909703Medicaid
NC09703OtherBLCROSS
NC8909703Medicaid