Provider Demographics
NPI:1851399414
Name:PENCE, JACK R II (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:PENCE
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:6680 POE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2854
Mailing Address - Country:US
Mailing Address - Phone:937-280-8366
Mailing Address - Fax:937-280-8373
Practice Address - Street 1:1911 N FAIRFIELD RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2762
Practice Address - Country:US
Practice Address - Phone:937-429-7352
Practice Address - Fax:937-429-3772
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2014-03-17
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Provider Licenses
StateLicense IDTaxonomies
OH35-043064208800000X
OH35043064208800000X
OH35043064P208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0622857Medicaid
OHC46429Medicare UPIN
C46429Medicare UPIN
OH0622857Medicaid