Provider Demographics
NPI:1457357964
Name:PENALVER, OVIDIO MOISES (MD, PS)
Entity Type:Individual
Prefix:DR
First Name:OVIDIO
Middle Name:MOISES
Last Name:PENALVER
Suffix:
Gender:M
Credentials:MD, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 5TH ST SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5828
Mailing Address - Country:US
Mailing Address - Phone:253-848-0351
Mailing Address - Fax:253-841-1397
Practice Address - Street 1:319 5TH ST SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5828
Practice Address - Country:US
Practice Address - Phone:253-848-0351
Practice Address - Fax:253-841-1397
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110653Medicaid
WAA08563Medicare UPIN