1700214368 NPI number — JOSE M PENA MD PA

Table of content: (NPI 1700214368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700214368 NPI number — JOSE M PENA MD PA

Organization/Personal Information

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

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:
1700214368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 SW 130TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33184-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-774-0742
Provider Business Mailing Address Fax Number:
305-774-0836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14740 SW 26TH ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33185-5830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-774-0742
Provider Business Practice Location Address Fax Number:
305-774-0836
Provider Enumeration Date:
10/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PENA
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-774-0742

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016838400 . 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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