MEDICARE: SERGIO PENUNURI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	852992	ZZ

General Provider Information

NPI Number	:	1164791612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERGIO PENUNURI

Provider Business Mailing Address
First Line	:	PO BOX 210116
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91921-0116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2340-408 J CLEMENTE OROZCO ST
Second Line	:
City	:	TIJUANA
State	:	BC
Zip	:	22320
Country	:	MX
Telephone Number	:	664-634-2898
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	MR. ALEJANDRO RAMOS
Credential	:
Telephone Number	:	619-992-6290

Provider Enumeration Date	:	12/28/2011
Last Update Date	:	12/28/2011

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Directions to “SERGIO PENUNURI ” Practice Location

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