Healthcare Provider Details

I. General information

NPI: 1154650117
Provider Name (Legal Business Name): PENELOPE MASHBURN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PENELOPE PAREDES D.O.

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 ST. LAWRENCE DR. SUITE203
TIFFIN OH
44883
US

IV. Provider business mailing address

2200 JEFFERSON AVE 4TH FLOOR
TOLEDO OH
43604-7101
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-9978
  • Fax: 419-455-8564
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberP12-00612
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34.011231
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: