Healthcare Provider Details

I. General information

NPI: 1295775922
Provider Name (Legal Business Name): DAVID J PENN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E MAIN ST
CARBONDALE KS
66414-9607
US

IV. Provider business mailing address

211 E MAIN ST
CARBONDALE KS
66414-9607
US

V. Phone/Fax

Practice location:
  • Phone: 785-836-7111
  • Fax: 785-836-9251
Mailing address:
  • Phone: 785-836-7111
  • Fax: 785-836-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-24443
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: