Provider Demographics
NPI:1134496474
Name:OMAR J PENA LOPEZ MD PA
Entity Type:Organization
Organization Name:OMAR J PENA LOPEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-307-8819
Mailing Address - Street 1:1403 CARNELIAN DR
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-4388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 CARNELIAN DR
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-4388
Practice Address - Country:US
Practice Address - Phone:956-307-8819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty