1386138030 NPI number — EMILIO MIGUEL PENA MD

Table of content: EMILIO MIGUEL PENA MD (NPI 1386138030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386138030 NPI number — EMILIO MIGUEL PENA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
EMILIO
Provider Middle Name:
MIGUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1386138030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 919771
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-278-3600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 SUMMER RIDGE LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-3289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-344-2307
Provider Business Practice Location Address Fax Number:
239-267-6219
Provider Enumeration Date:
06/17/2018

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: 208000000X , with the licence number:  ME150763 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111688400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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