Provider Demographics
NPI:1235630989
Name:DR. CESAR PENA MD, PA
Entity Type:Organization
Organization Name:DR. CESAR PENA MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-565-3288
Mailing Address - Street 1:9101 LBJ FWY STE 425
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2057
Mailing Address - Country:US
Mailing Address - Phone:817-565-3288
Mailing Address - Fax:
Practice Address - Street 1:3232 BROADWAY BLVD STE A
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1728
Practice Address - Country:US
Practice Address - Phone:972-905-5134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1073576435OtherINDIVIDUAL NPI