1225174816 NPI number — DR. IVELISSE PENA JIMENO MD

Table of content: DR. IVELISSE PENA JIMENO MD (NPI 1225174816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225174816 NPI number — DR. IVELISSE PENA JIMENO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA JIMENO
Provider First Name:
IVELISSE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225174816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOA BAJA
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00950-1320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-751-2653
Provider Business Mailing Address Fax Number:
787-753-4807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
346 CALLE 32
Provider Second Line Business Practice Location Address:
VILLA NEVAREZ
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00927-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-751-2653
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  12440 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20041 . This is a "TRIPLE S" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 500475E . This is a "MMM" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 9270157 . This is a "HUMANA" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 2499 . This is a "PMC" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 5234 . This is a "FIRST MEDICAL" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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