Provider Demographics
NPI:1194782185
Name:PENLY, RICHARD T (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:PENLY
Suffix:
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 1:6005 65TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-5231
Mailing Address - Country:US
Mailing Address - Phone:772-532-2151
Mailing Address - Fax:
Practice Address - Street 1:1600 37TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4863
Practice Address - Country:US
Practice Address - Phone:772-532-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB25442Medicare UPIN
FL358132Medicare ID - Type Unspecified