Provider Demographics
NPI:1982671541
Name:PENNER, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
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 1:681 THIRD AVENUE
Mailing Address - Street 2:STE. B
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-425-2150
Mailing Address - Fax:619-425-2848
Practice Address - Street 1:681 THIRD AVENUE
Practice Address - Street 2:STE. B
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-425-2150
Practice Address - Fax:619-425-2848
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5922207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067510Medicaid
WG5922DMedicare PIN
A57399Medicare UPIN