Provider Demographics
NPI:1073649141
Name:PENAHERRERA, JOSE ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANTONIO
Last Name:PENAHERRERA
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 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:SUITE 265
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9524
Mailing Address - Country:US
Mailing Address - Phone:815-727-4292
Mailing Address - Fax:815-727-5395
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:SUITE 265
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9524
Practice Address - Country:US
Practice Address - Phone:815-727-4292
Practice Address - Fax:815-727-5395
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095226207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9928146OtherBC/BS
IL9928146OtherBC/BS
G47083Medicare UPIN