MEDICARE: KEVIN MATTHEW PENNYCOOK DO

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	207N00000X	Dermatology Physician	OS19718	FL

General Provider Information

NPI Number	:	1922661040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN MATTHEW PENNYCOOK DO

Provider Business Mailing Address
First Line	:	900 VILLAGE SQUARE XING STE 290
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-4552
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3268 FORUM BLVD STE 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-5585
Country	:	US
Telephone Number	:	239-232-1176
Fax Number	:	239-244-9839

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

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	09/01/2023

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