Provider Demographics
NPI:1154650117
Name:MASHBURN, PENELOPE (DO)
Entity type:Individual
Prefix:MRS
First Name:PENELOPE
Middle Name:
Last Name:MASHBURN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PENELOPE
Other - Middle Name:
Other - Last Name:PAREDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 ST. LAWRENCE DR.
Practice Address - Street 2:SUITE203
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883
Practice Address - Country:US
Practice Address - Phone:305-575-9978
Practice Address - Fax:419-455-8564
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.011231208600000X
NJP12-00612390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0106134Medicaid
OH34011231OtherOHIO MEDICAL LICENSE
OH34011231OtherOHIO MEDICAL LICENSE