Provider Demographics
NPI:1770755985
Name:PENN, JUSTIN D (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:PENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2520 CHERRY AVE
Mailing Address - Street 2:HARRISON MEDICAL CENTER
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4229
Mailing Address - Country:US
Mailing Address - Phone:360-373-2547
Mailing Address - Fax:360-479-8268
Practice Address - Street 1:2709 HEMLOCK ST
Practice Address - Street 2:HARRISON HEALTHPARTNERS CARDIOVASCULAR CONSULTANTS
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2623
Practice Address - Country:US
Practice Address - Phone:360-373-2547
Practice Address - Fax:360-479-8268
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
NY256268208M00000X, 207R00000X
WAMD60544826207RC0000X
CO054224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO024975OtherKAISER COMMERCIAL NUMBER
WA2044356Medicaid
WAG8940389OtherMEDICARE
CO94509719Medicaid
CO024975OtherKAISER COMMERCIAL NUMBER