Healthcare Provider Details

I. General information

NPI: 1629287750
Provider Name (Legal Business Name): PHILIP J PENROSE M D A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 UPPER RAGSDALE DR 200
MONTEREY CA
93940-7831
US

IV. Provider business mailing address

21 UPPER RAGSDALE DR 200
MONTEREY CA
93940-7831
US

V. Phone/Fax

Practice location:
  • Phone: 831-372-1500
  • Fax: 831-655-6493
Mailing address:
  • Phone: 831-372-1500
  • Fax: 831-655-6493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA78833
License Number StateCA

VIII. Authorized Official

Name: PHILIP J PENROSE
Title or Position: OWNER
Credential: M.D.
Phone: 831-372-1500