Healthcare Provider Details

I. General information

NPI: 1164463402
Provider Name (Legal Business Name): PENNY ROBILLARD VANDESTREEK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA DR ATT: NUCLEAR MEDICINE
ROSEVILLE CA
95661-3037
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD #100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-781-1292
  • Fax: 916-663-9912
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0903X
TaxonomyIn Vivo & In Vitro Nuclear Medicine Physician
License Number20A6232
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number20A6232
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number20A6232
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number20A6232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: