Provider Demographics
NPI:1003098658
Name:PENA, WILLIE (MD, DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:MD, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 W BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8201 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2701
Practice Address - Country:US
Practice Address - Phone:954-999-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9373111N00000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No111N00000XChiropractic ProvidersChiropractor