Provider Demographics
NPI:1770690091
Name:PENNINGTON, ROY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:DAVID
Last Name:PENNINGTON
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 1:1014 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-5103
Mailing Address - Country:US
Mailing Address - Phone:601-324-9403
Mailing Address - Fax:601-936-0686
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13496207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS050078275OtherMEDICARE RAILROAD
MS00112194Medicaid
MS00112194Medicaid
MS050078275OtherMEDICARE RAILROAD