Healthcare Provider Details

I. General information

NPI: 1164420295
Provider Name (Legal Business Name): JUAN C PENHOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 COLUMBUS AVE
SANDUSKY OH
44870-5719
US

IV. Provider business mailing address

3703 COLUMBUS AVE
SANDUSKY OH
44870-5719
US

V. Phone/Fax

Practice location:
  • Phone: 419-625-8085
  • Fax: 419-625-6004
Mailing address:
  • Phone: 419-625-8085
  • Fax: 419-625-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number35058356P
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: