MEDICARE: DR. JESSE PULLEN PENICO 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	207RI0200X	Infectious Disease Physician	ME72349	FL
2	207RI0200X	Infectious Disease Physician	015311	LA
3	207RI0200X	Infectious Disease Physician	21358	MS

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912904590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE PULLEN PENICO MD

Provider Business Mailing Address
First Line	:	PO BOX 1810
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39502-1810
Country	:	US
Telephone Number	:	228-575-2700
Fax Number	:	228-575-2710

Provider Business Practice Location Address
First Line	:	1340 BROAD AVE
Second Line	:	SUITE 300
City	:	GULFPORT
State	:	MS
Zip	:	39501-2404
Country	:	US
Telephone Number	:	228-575-2700
Fax Number	:	228-575-2709

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	09/22/2020

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Directions to “ DR. JESSE PULLEN PENICO MD” Practice Location

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