Healthcare Provider Details

I. General information

NPI: 1285637553
Provider Name (Legal Business Name): JESUS L PENABAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 FIVAY RD STE 250
HUDSON FL
34667-7151
US

IV. Provider business mailing address

14100 FIVAY RD STE 250
HUDSON FL
34667-7151
US

V. Phone/Fax

Practice location:
  • Phone: 727-869-7822
  • Fax: 727-862-0934
Mailing address:
  • Phone: 727-869-7822
  • Fax: 727-862-0934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME0066672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: