1093974511 NPI number — REO MALACHI PENISTON M.D.

Table of content: REO MALACHI PENISTON M.D. (NPI 1093974511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093974511 NPI number — REO MALACHI PENISTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENISTON
Provider First Name:
REO
Provider Middle Name:
MALACHI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093974511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 S WOODLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER GARDEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34787-3546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-905-8827
Provider Business Mailing Address Fax Number:
407-905-8998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1296 W BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROVELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34736-2012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-905-8827
Provider Business Practice Location Address Fax Number:
352-429-5606
Provider Enumeration Date:
06/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  264985-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108872000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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