1720441207 NPI number — DR. ROY MASON PENNINGTON III MD

Table of content: DR. ROY MASON PENNINGTON III MD (NPI 1720441207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720441207 NPI number — DR. ROY MASON PENNINGTON III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNINGTON
Provider First Name:
ROY
Provider Middle Name:
MASON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720441207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 WHITE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-449-6500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 FORRESTAL DR BLDG 33
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23551-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-953-3647
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101263036 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com