Provider Demographics
NPI:1639480247
Name:PENKAR, MANEESH SURESH (MD)
Entity Type:Individual
Prefix:
First Name:MANEESH
Middle Name:SURESH
Last Name:PENKAR
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 1:23560 MADISON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4710
Mailing Address - Country:US
Mailing Address - Phone:424-328-0203
Mailing Address - Fax:424-328-0204
Practice Address - Street 1:3701 SKYPARK DR STE 105
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4712
Practice Address - Country:US
Practice Address - Phone:310-373-1400
Practice Address - Fax:310-791-7977
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL32972207R00000X
NC2013-01695207R00000X
CAC167686207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1887Medicaid
NC1639480247Medicaid
NCNCE626AMedicare PIN