Individual
DR. JESSE PULLEN PENICO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1340 BROAD AVE, SUITE 300, GULFPORT, MS 39501-2404
(228) 575-2700
(228) 575-2709
Mailing address
PO BOX 1810, GULFPORT, MS 39502-1810
(228) 575-2700
(228) 575-2710
Taxonomy
Speciality
Code
Description
License number
State
207RI0200X
Infectious Disease Physician
015311
LA
207RI0200X
Infectious Disease Physician
Primary
21358
MS
207RI0200X
Infectious Disease Physician
ME72349
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00112089
—
MS
05
—
1339181
—
LA
Enumeration date
06/28/2005
Last updated
09/22/2020
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