Provider Demographics
NPI:1922661040
Name:PENNYCOOK, KEVIN MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATTHEW
Last Name:PENNYCOOK
Suffix:
Gender:M
Credentials:DO
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 STE 290
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3268 FORUM BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5585
Practice Address - Country:US
Practice Address - Phone:239-232-1176
Practice Address - Fax:239-244-9839
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS19718207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology