MEDICARE: JAN R PENVOSE-YI 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	207V00000X	Obstetrics & Gynecology Physician	P132992	CA
2	207V00000X	Obstetrics & Gynecology Physician	238705	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000528650003	OTHER	NY	BCBS
2	00027679002	OTHER	NY	UNIVERA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0713851	OTHER	NY	IHA

General Provider Information

NPI Number	:	1932203478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN R PENVOSE-YI MD

Provider Business Mailing Address
First Line	:	3998 VISTA WAY STE C
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92056-4514
Country	:	US
Telephone Number	:	760-385-8008
Fax Number	:	760-385-8007

Provider Business Practice Location Address
First Line	:	3998 VISTA WAY STE C
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92056-4514
Country	:	US
Telephone Number	:	760-385-8008
Fax Number	:	760-385-8007

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

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	04/23/2018

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Directions to “ JAN R PENVOSE-YI MD” Practice Location

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