Healthcare Provider Details

I. General information

NPI: 1457357964
Provider Name (Legal Business Name): OVIDIO MOISES PENALVER MD, PS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 5TH ST SW
PUYALLUP WA
98371-5828
US

IV. Provider business mailing address

319 5TH ST SW
PUYALLUP WA
98371-5828
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-0351
  • Fax: 253-841-1397
Mailing address:
  • Phone: 253-848-0351
  • Fax: 253-841-1397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD00015660
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: