Provider Demographics
NPI:1154602324
Name:PENNISI, JOHN ANTHONY (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:PENNISI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1845 VETERANS PARK DR STE 210
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0493
Mailing Address - Country:US
Mailing Address - Phone:239-624-0530
Mailing Address - Fax:239-624-0531
Practice Address - Street 1:1845 VETERANS PARK DR STE 210
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0493
Practice Address - Country:US
Practice Address - Phone:239-624-0530
Practice Address - Fax:239-634-0531
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS14158207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018289700Medicaid
FLNT1FUOtherBCBS
FLMEDICAREOtherIQ861Z