Healthcare Provider Details

I. General information

NPI: 1124383583
Provider Name (Legal Business Name): JEFFREY ROBERT PENTEK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 WINTERGREEN LN NE
BAINBRIDGE ISLAND WA
98110
US

IV. Provider business mailing address

1344 WINTERGREEN LN NE
BAINBRIDGE ISLAND WA
98110-5118
US

V. Phone/Fax

Practice location:
  • Phone: 206-842-5632
  • Fax: 206-842-5992
Mailing address:
  • Phone: 206-842-5632
  • Fax: 206-842-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPO60560146
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002464
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: