Provider Demographics
NPI:1225174816
Name:PENA JIMENO, IVELISSE (MD)
Entity Type:Individual
Prefix:DR
First Name:IVELISSE
Middle Name:
Last Name:PENA JIMENO
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:PO BOX 51320
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1320
Mailing Address - Country:US
Mailing Address - Phone:787-751-2653
Mailing Address - Fax:787-753-4807
Practice Address - Street 1:346 CALLE 32
Practice Address - Street 2:VILLA NEVAREZ
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-5111
Practice Address - Country:US
Practice Address - Phone:787-751-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20041OtherTRIPLE S
PR500475EOtherMMM
PR9270157OtherHUMANA
PR2499OtherPMC
PR5234OtherFIRST MEDICAL
PR5234OtherFIRST MEDICAL
PRH82855Medicare UPIN