Healthcare Provider Details

I. General information

NPI: 1144853649
Provider Name (Legal Business Name): CHARLES PENVOSE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 TAMARACK RD
NEWARK OH
43055-2303
US

IV. Provider business mailing address

1920 TAMARACK RD
NEWARK OH
43055-2303
US

V. Phone/Fax

Practice location:
  • Phone: 740-344-8286
  • Fax: 740-522-0094
Mailing address:
  • Phone: 740-344-8286
  • Fax: 740-522-0094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001444
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003998
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: