Provider Demographics
NPI:1700889607
Name:PENNOCK, GREGORY D (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:PENNOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:423 N THIRD AVE STE 335
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-265-7070
Practice Address - Fax:208-265-7071
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2018-06-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
IDM12621207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE45443Medicare UPIN
AZZ67657Medicare PIN