Provider Demographics
NPI:1073657482
Name:MENA, ROBERT MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:MENA
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 1:718 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:WINNIE
Mailing Address - State:TX
Mailing Address - Zip Code:77665-8890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:538 BROADWAY
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665-7600
Practice Address - Country:US
Practice Address - Phone:409-296-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT0566207Q00000X
IDM8898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID55392OtherBLUE CROSS
ID1111689OtherMEDICARE
ID000010144342OtherBLUE SHIELD OF IDAHO
ID806670100Medicaid
ID820227163B004OtherTRICARE
ID820227163G041OtherTRICARE
ID000010144054OtherBLUE SHIELD OF IDAHO
ID553925OtherBLUE CROSS OF IDAHO
IDJ9430OtherBLUE CROSS OF IDAHO
ID55392OtherBLUE CROSS
IDJ9430OtherBLUE CROSS OF IDAHO