Provider Demographics
NPI:1811103542
Name:PENNINGTON, CRYSTAL ROSE (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:PENNINGTON
Suffix:
Gender:F
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:PO BOX 1426
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-1426
Mailing Address - Country:US
Mailing Address - Phone:479-452-9416
Mailing Address - Fax:
Practice Address - Street 1:7301 ROGERS AVE
Practice Address - Street 2:BOX 1426
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4100
Practice Address - Country:US
Practice Address - Phone:479-441-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7102207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193382001Medicaid
OK200441210AMedicaid
OK200441210AMedicaid