Provider Demographics
NPI:1003626458
Name:JOHN CORNELIUS PENNER, MD
Entity type:Organization
Organization Name:JOHN CORNELIUS PENNER, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-490-2043
Mailing Address - Street 1:69 HERNANDEZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5844
Mailing Address - Country:US
Mailing Address - Phone:408-204-6990
Mailing Address - Fax:
Practice Address - Street 1:69 HERNANDEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5844
Practice Address - Country:US
Practice Address - Phone:408-204-6990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty