Provider Demographics
NPI:1548947971
Name:PENROSE, O'CONNELL CALEB
Entity type:Individual
Prefix:
First Name:O'CONNELL
Middle Name:CALEB
Last Name:PENROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 SPRING ST NE STE 710
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3715
Mailing Address - Country:US
Mailing Address - Phone:770-219-0020
Mailing Address - Fax:
Practice Address - Street 1:743 SPRING ST NE REAR 710
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3899
Practice Address - Country:US
Practice Address - Phone:770-219-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine