Provider Demographics
NPI:1861521148
Name:PENKALA, JAN J (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:J
Last Name:PENKALA
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 1:6 BLACKSTONE VALLEY PL
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1179
Mailing Address - Country:US
Mailing Address - Phone:401-334-2229
Mailing Address - Fax:401-333-2454
Practice Address - Street 1:6 BLACKSTONE VALLEY PL
Practice Address - Street 2:SUITE 501
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1179
Practice Address - Country:US
Practice Address - Phone:401-334-2229
Practice Address - Fax:401-333-2454
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD6052207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C90536Medicare UPIN
RI1690012151Medicare PIN