Provider Demographics
NPI:1770755985
Name:PENN, JUSTIN D (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:PENN
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 1:1950 NW MYHRE RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7662
Mailing Address - Country:US
Mailing Address - Phone:564-240-4200
Mailing Address - Fax:564-240-4299
Practice Address - Street 1:1950 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7662
Practice Address - Country:US
Practice Address - Phone:564-240-4200
Practice Address - Fax:564-240-4200
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256268207R00000X, 208M00000X
CO054224207R00000X
390200000X
WAMD60544826207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94509719Medicaid
WAG8940389OtherMEDICARE
CO024975OtherKAISER COMMERCIAL NUMBER
WA2044356Medicaid
CO024975OtherKAISER COMMERCIAL NUMBER