Provider Demographics
NPI:1265431399
Name:PENILLA, ANTONIO R (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:R
Last Name:PENILLA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE. 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-953-6300
Mailing Address - Fax:314-953-6309
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:STE 2310C
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-953-6300
Practice Address - Fax:314-953-6309
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-01-30
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Provider Licenses
StateLicense IDTaxonomies
MO33875207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200920817Medicaid
P00320613OtherRR MCR
IL7480467052OtherIDPA
MO916304884Medicare PIN
P00320613OtherRR MCR
MOA10822Medicare UPIN