Provider Demographics
NPI:1336187079
Name:PENSO, JERROLD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:LEE
Last Name:PENSO
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1102 NEPTUNE AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1427
Mailing Address - Country:US
Mailing Address - Phone:760-943-8636
Mailing Address - Fax:760-943-7961
Practice Address - Street 1:2001 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2303
Practice Address - Country:US
Practice Address - Phone:619-446-1638
Practice Address - Fax:619-696-1579
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CAG67126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF03193Medicare UPIN