Provider Demographics
NPI:1629063722
Name:PENCE, JEFFREY C (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:PENCE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:175 WHITE ST NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7901
Practice Address - Country:US
Practice Address - Phone:943-202-7820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95001782086S0120X
OH35.0924042086S0120X
VA01012777152086S0120X
GA2086S0120X2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912334Medicaid
OH2881645Medicaid
NC370015118OtherRAILROAD MEDICARE
NC12334OtherBCBS NC
NC12334OtherBCBS NC