Provider Demographics
NPI:1770839664
Name:PENNINGTON, OBBIE (OD)
Entity Type:Individual
Prefix:
First Name:OBBIE
Middle Name:
Last Name:PENNINGTON
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 1:2109 FOREST AVE
Mailing Address - Street 2:SUITE 50
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-7708
Mailing Address - Country:US
Mailing Address - Phone:530-342-9644
Mailing Address - Fax:530-342-7547
Practice Address - Street 1:2109 FOREST AVE
Practice Address - Street 2:SUITE 50
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-7708
Practice Address - Country:US
Practice Address - Phone:530-342-9644
Practice Address - Fax:530-342-7547
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA122066OtherMEDICARE PTAN