Provider Demographics
NPI:1255304903
Name:PENSE, STANLEY C (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:C
Last Name:PENSE
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 194
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-0194
Mailing Address - Country:US
Mailing Address - Phone:541-329-0144
Mailing Address - Fax:541-824-0460
Practice Address - Street 1:209 N CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1274
Practice Address - Country:US
Practice Address - Phone:541-329-0144
Practice Address - Fax:541-824-0460
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD175323208D00000X
CO45100208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25424556Medicaid
AZ216417Medicaid
AZ216417Medicaid
MD23170Medicare ID - Type Unspecified
COC90983Medicare UPIN