Healthcare Provider Details

I. General information

NPI: 1548245319
Provider Name (Legal Business Name): JASON PENZER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MADISON AVE SUITE 705
NEW YORK NY
10022-5403
US

IV. Provider business mailing address

515 MADISON AVE SUITE 705
NEW YORK NY
10022-5403
US

V. Phone/Fax

Practice location:
  • Phone: 212-675-2997
  • Fax: 212-627-8389
Mailing address:
  • Phone: 212-675-2997
  • Fax: 212-627-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number207364
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: