Provider Demographics
NPI:1174595516
Name:PENMATCHA, ASHOK R (MD)
Entity type:Individual
Prefix:
First Name:ASHOK
Middle Name:R
Last Name:PENMATCHA
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 1:1230 E RUSHOLME ST
Mailing Address - Street 2:STE 203
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2400
Mailing Address - Country:US
Mailing Address - Phone:563-322-0923
Mailing Address - Fax:563-322-7403
Practice Address - Street 1:1230 E RUSHOLME ST
Practice Address - Street 2:STE 203
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2400
Practice Address - Country:US
Practice Address - Phone:563-322-0923
Practice Address - Fax:563-322-7403
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA31845207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0156885Medicaid
IA59311OtherWELLMARK BCBS
180031058Medicare PIN
G51883Medicare UPIN
IA71964Medicare PIN
IA0156885Medicaid
IA59311OtherWELLMARK BCBS
IA0535960001Medicare NSC