Provider Demographics
NPI:1295775922
Name:PENN, DAVID J (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:PENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:KS
Mailing Address - Zip Code:66414-9607
Mailing Address - Country:US
Mailing Address - Phone:785-836-7111
Mailing Address - Fax:785-836-9251
Practice Address - Street 1:211 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:KS
Practice Address - Zip Code:66414-9607
Practice Address - Country:US
Practice Address - Phone:785-836-7111
Practice Address - Fax:785-836-9251
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS067059OtherMEDICARE PTAN
KS100159180BMedicaid
KS100159180BMedicaid