Provider Demographics
NPI:1841436532
Name:JAMES H PENNINGTON OD
Entity type:Organization
Organization Name:JAMES H PENNINGTON OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-485-6211
Mailing Address - Street 1:6421 GEORGETOWN NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7007
Mailing Address - Country:US
Mailing Address - Phone:260-485-6211
Mailing Address - Fax:260-492-0741
Practice Address - Street 1:6421 GEORGETOWN NORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7007
Practice Address - Country:US
Practice Address - Phone:260-485-6211
Practice Address - Fax:260-492-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001491A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4402530001Medicare NSC