Provider Demographics
NPI:1841351228
Name:PENNELL, CRAIG S (OD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:S
Last Name:PENNELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-8196
Mailing Address - Country:US
Mailing Address - Phone:859-363-3347
Mailing Address - Fax:
Practice Address - Street 1:1824 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-8432
Practice Address - Country:US
Practice Address - Phone:859-363-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1168DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0966101OtherMEDICARE ID
KY77011682Medicaid