Individual
JOHN PENUEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
821 N COBB ST, MILLEDGEVILLE, GA 31061-2343
(478) 452-0524
(478) 452-0525
Mailing address
1854 SHACKLEFORD CT, SUITE 350, NORCROSS, GA 30093-2954
(770) 688-3801
(770) 237-6148
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
9900983
NC
2085R0202X
Diagnostic Radiology Physician
Primary
048926
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00926483D
—
GA
01
—
048926
LICENSE
GA
01
—
581593676
TAX IDENTIFICATION
GA
01
—
P00991552
RR MEDICARE
GA
Enumeration date
07/18/2005
Last updated
03/07/2023
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