Healthcare Provider Details

I. General information

NPI: 1003626458
Provider Name (Legal Business Name): JOHN CORNELIUS PENNER, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 HERNANDEZ AVE
LOS GATOS CA
95030-5844
US

IV. Provider business mailing address

69 HERNANDEZ AVE
LOS GATOS CA
95030-5844
US

V. Phone/Fax

Practice location:
  • Phone: 408-204-6990
  • Fax:
Mailing address:
  • Phone: 408-204-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACI CROSBY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 715-490-2043