Healthcare Provider Details

I. General information

NPI: 1629063722
Provider Name (Legal Business Name): JEFFREY CARL PENCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 WHITE ST NW STE 200
MARIETTA GA
30060-7901
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 943-202-7820
  • Fax:
Mailing address:
  • Phone: 540-224-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number9500178
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35.092404
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number0101277715
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number2086S0120X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: