Provider Demographics
NPI:1174508683
Name:PENA, SELENE (MD)
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 AVE. ALBOLOTE
Mailing Address - Street 2:PLAZA REAL SUITE 310
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-300-5488
Mailing Address - Fax:787-300-5487
Practice Address - Street 1:1 AVE. ALBOLOTE
Practice Address - Street 2:PLAZA REAL SUITE 310
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:787-300-5488
Practice Address - Fax:787-300-5487
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2123462084P0800X
PR146952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H-51813Medicare UPIN
PR8-2247ALMedicare ID - Type UnspecifiedGROUP PRACTICE