Provider Demographics
NPI:1114322070
Name:PENAGOS, VICTOR (HSE 11988)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:PENAGOS
Suffix:
Gender:M
Credentials:HSE 11988
Other - Prefix:DR
Other - First Name:VICTOR
Other - Middle Name:MARIO
Other - Last Name:PENAGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HSE 11988
Mailing Address - Street 1:22198 BELLA LAGO DR APT 1118
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-4839
Mailing Address - Country:US
Mailing Address - Phone:561-419-7295
Mailing Address - Fax:
Practice Address - Street 1:22198 BELLA LAGO DR APT 1118
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-4839
Practice Address - Country:US
Practice Address - Phone:561-777-9952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE 11988246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant