Provider Demographics
NPI:1932203478
Name:PENVOSE-YI, JAN R (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:R
Last Name:PENVOSE-YI
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 1:3998 VISTA WAY STE C
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4514
Mailing Address - Country:US
Mailing Address - Phone:760-385-8008
Mailing Address - Fax:760-385-8007
Practice Address - Street 1:3998 VISTA WAY STE C
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4514
Practice Address - Country:US
Practice Address - Phone:760-385-8008
Practice Address - Fax:760-385-8007
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP132992207V00000X
NY238705207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000528650003OtherBCBS
NY00027679002OtherUNIVERA
NY02780101Medicaid
NY0713851OtherIHA
NY000528650003OtherBCBS
NYJ400000767Medicare PIN