MEDICARE: DR. VINCENT PENNISI MD

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	207R00000X	Internal Medicine Physician	A186288	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306375662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VINCENT PENNISI MD

Provider Business Mailing Address
First Line	:	1503 E MARCH LN STE A
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95210-5622
Country	:	US
Telephone Number	:	209-334-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1503 E MARCH LN STE A
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95210-5622
Country	:	US
Telephone Number	:	209-747-3987
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	08/03/2023

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