Healthcare Provider Details

I. General information

NPI: 1073598132
Provider Name (Legal Business Name): GERALD MELVILLE PENN M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 SHAWAN FALLS DR
DUBLIN OH
43017-2100
US

IV. Provider business mailing address

650 SHAWAN FALLS DR
DUBLIN OH
43017-2100
US

V. Phone/Fax

Practice location:
  • Phone: 614-764-1711
  • Fax: 614-889-2652
Mailing address:
  • Phone: 614-764-1711
  • Fax: 614-889-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number35027499
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: