Healthcare Provider Details

I. General information

NPI: 1720441207
Provider Name (Legal Business Name): ROY MASON PENNINGTON III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 12/01/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 FORRESTAL DR BLDG 33
NORFOLK VA
23551-0001
US

IV. Provider business mailing address

100 WHITE STREET
JACKSONVILLE NC
28540
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3647
  • Fax:
Mailing address:
  • Phone: 910-449-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101263036
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: