Healthcare Provider Details

I. General information

NPI: 1205806452
Provider Name (Legal Business Name): JOHAN J PENNINCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 MURCHISON DR
EL PASO TX
79902
US

IV. Provider business mailing address

1720 MURCHISON DR
EL PASO TX
79902
US

V. Phone/Fax

Practice location:
  • Phone: 915-533-7465
  • Fax: 915-534-5289
Mailing address:
  • Phone: 915-533-7465
  • Fax: 915-534-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberH1638
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: