Basic Information
| Provider Information | |||||||||
| NPI: | 1154488419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10530 DISCOVERY DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891353050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028022832 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 ARCH ST STE 3A | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753584 | ||||||||
| FaxNumber: | 3303756306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | 35042202 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207Q00000X | 15507 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0396361 | 05 | OH | MEDICAID |