Provider Demographics
NPI:1588787998
Name:PENROD, WILLIAM JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:PENROD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 W 25TH AVE
Mailing Address - Street 2:#4
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2298
Mailing Address - Country:US
Mailing Address - Phone:650-349-2222
Mailing Address - Fax:
Practice Address - Street 1:190 W 25TH AVE
Practice Address - Street 2:#4
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2298
Practice Address - Country:US
Practice Address - Phone:650-349-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91-2036165Medicare UPIN