Provider Demographics
NPI:1548703036
Name:PENNISI, DOMINIC (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:PENNISI
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:PO BOX 1434
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1434
Mailing Address - Country:US
Mailing Address - Phone:209-462-7277
Mailing Address - Fax:866-950-0134
Practice Address - Street 1:832 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5117
Practice Address - Country:US
Practice Address - Phone:209-365-9331
Practice Address - Fax:209-365-9359
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA175794207R00000X
NYP01331208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP01331OtherLIMITED-LICENSE