Provider Demographics
NPI:1962449892
Name:PENICK, EDWARD M III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:PENICK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5 ST. VINCENT CIRCLE, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5412
Mailing Address - Country:US
Mailing Address - Phone:501-664-5354
Mailing Address - Fax:501-664-5257
Practice Address - Street 1:5 ST. VINCENT CIRCLE, SUITE 101
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5412
Practice Address - Country:US
Practice Address - Phone:501-664-5354
Practice Address - Fax:501-664-5257
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4798207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160765001Medicaid
ARP00337243OtherRAILROAD MEDICARE
AR160765001Medicaid
153156Medicare UPIN