Provider Demographics
NPI:1912904590
Name:PENICO, JESSE PULLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:PULLEN
Last Name:PENICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-2700
Mailing Address - Fax:228-575-2710
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-2700
Practice Address - Fax:228-575-2709
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72349207RI0200X
LA015311207RI0200X
MS21358207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112089Medicaid
LA1339181Medicaid
LAC67301Medicare UPIN
LA1339181Medicaid