Provider Demographics
NPI:1710019187
Name:PENROSE, DEBORAH B (DO)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:B
Last Name:PENROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019
Mailing Address - Country:US
Mailing Address - Phone:650-726-1200
Mailing Address - Fax:650-726-1235
Practice Address - Street 1:725 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019
Practice Address - Country:US
Practice Address - Phone:650-726-1200
Practice Address - Fax:650-726-1235
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E08803Medicare UPIN