Healthcare Provider Details

I. General information

NPI: 1336165125
Provider Name (Legal Business Name): STEPHEN T. PENEPACKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4700
  • Fax: 805-781-1232
Mailing address:
  • Phone: 805-781-4700
  • Fax: 805-781-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC180768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: