Provider Demographics
NPI:1992784615
Name:PENNINGTON, GERARD M (MD)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:M
Last Name:PENNINGTON
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 1:1305 WONDER WORLD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7546
Mailing Address - Country:US
Mailing Address - Phone:512-353-8661
Mailing Address - Fax:512-353-8355
Practice Address - Street 1:1305 WONDER WORLD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7546
Practice Address - Country:US
Practice Address - Phone:512-353-8661
Practice Address - Fax:512-353-8355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1347207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF27551Medicare UPIN
TX83M167Medicare ID - Type Unspecified