Provider Demographics
NPI:1982657979
Name:PENICO III, PETER E (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:PENICO III
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 1:18167 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 285
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-3528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4604
Practice Address - Country:US
Practice Address - Phone:941-798-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36495207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL41193OtherBCBS
FL036286700Medicaid
FL930084466Medicare PIN
FL036286700Medicaid
FL41139MMedicare PIN
FL41193OMedicare PIN