Provider Demographics
NPI:1710415823
Name:PENNELL, GARRETT (OD)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:PENNELL
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 1:4130 LA JOLLA VILLAGE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1481
Mailing Address - Country:US
Mailing Address - Phone:858-455-6800
Mailing Address - Fax:
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR STE 300
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1481
Practice Address - Country:US
Practice Address - Phone:858-455-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist