Provider Demographics
NPI:1932321643
Name:PENNER, MONTE WINSTON (MD)
Entity Type:Individual
Prefix:DR
First Name:MONTE
Middle Name:WINSTON
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:PO BOX 923
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:CA
Mailing Address - Zip Code:95736-0923
Mailing Address - Country:US
Mailing Address - Phone:916-215-1531
Mailing Address - Fax:916-481-6678
Practice Address - Street 1:2901 K ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-448-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG071997207R00000X
CAG71997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932321643Medicaid