Healthcare Provider Details

I. General information

NPI: 1134285430
Provider Name (Legal Business Name): JERI L PENKAVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 NE LOOP 410 STE 245
SAN ANTONIO TX
78216-5802
US

IV. Provider business mailing address

323 OGDEN LN
SAN ANTONIO TX
78209-5138
US

V. Phone/Fax

Practice location:
  • Phone: 210-403-2343
  • Fax: 210-403-2350
Mailing address:
  • Phone: 210-403-2343
  • Fax: 210-403-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG4242
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberG4242
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: