Provider Demographics
NPI:1760484604
Name:PENTA, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:PENTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:950 BRECKENRIDGE LN STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5929
Practice Address - Country:US
Practice Address - Phone:502-893-6777
Practice Address - Fax:502-899-5535
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21548207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000247085OtherANTHEM
50000082OtherPASSPORT
KYP01026547OtherMEDICARE RAILROAD
KY64215486Medicaid
KY64215486Medicaid
KYK003811Medicare Oscar/Certification
C69160Medicare UPIN
7548Medicare PIN