Provider Demographics
NPI:1790883601
Name:PENNER, JEFFREY STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STUART
Last Name:PENNER
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 1:900 VILLAGE SQUARE XING
Mailing Address - Street 2:STE 170
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4547
Mailing Address - Country:US
Mailing Address - Phone:561-967-4400
Mailing Address - Fax:561-967-5277
Practice Address - Street 1:130 JOHN F KENNEDY DR STE 201
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1142
Practice Address - Country:US
Practice Address - Phone:561-967-4400
Practice Address - Fax:561-967-5277
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030380174400000X
FLME30380207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037798800Medicaid
FL206593OtherAVMED
FL50805OtherBCBS
FL50805OtherBCBS
FLD85886Medicare UPIN
FLAG608ZMedicare PIN