Provider Demographics
NPI:1700802832
Name:PENN, THOMAS E (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:PENN
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 1:919 WESTFALL RD STE B100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2628
Mailing Address - Country:US
Mailing Address - Phone:585-454-6610
Mailing Address - Fax:585-454-6564
Practice Address - Street 1:919 WESTFALL RD STE B100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2628
Practice Address - Country:US
Practice Address - Phone:585-454-6610
Practice Address - Fax:585-454-6564
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00446337Medicaid
NY00446337Medicaid
RA0416Medicare PIN