Healthcare Provider Details

I. General information

NPI: 1588677058
Provider Name (Legal Business Name): MARY TRINH PENTEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 SUNBEAM RD SUITE 101
JACKSONVILLE FL
32257-6107
US

IV. Provider business mailing address

PO BOX 13859
TALLAHASSEE FL
32317-3859
US

V. Phone/Fax

Practice location:
  • Phone: 904-880-0622
  • Fax: 904-880-0623
Mailing address:
  • Phone: 850-205-6232
  • Fax: 855-975-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME76473
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME76473
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: