Provider Demographics
NPI:1124524038
Name:PENNELLA, SAMUEL JR (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:PENNELLA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 GLENNON FARM LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NJ
Mailing Address - Zip Code:08833-4504
Mailing Address - Country:US
Mailing Address - Phone:908-208-8926
Mailing Address - Fax:
Practice Address - Street 1:1905 N SHERMAN ST STE 200
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-1132
Practice Address - Country:US
Practice Address - Phone:908-208-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTW00059208D00000X
MN68449208D00000X
MI4301510893208D00000X
FLTPME2986208D00000X
CODR.0074417208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice