Provider Demographics
NPI:1235913724
Name:PENA, EDUARDO (IDHS)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COMMANDING OFFICER USCGC CUTTER VALIANT
Mailing Address - Street 2:NAVAL STATION MAYPORT PO BOX 280101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32228
Mailing Address - Country:US
Mailing Address - Phone:410-507-6476
Mailing Address - Fax:
Practice Address - Street 1:USCGC VALIANT - COMMANDING OFFICER
Practice Address - Street 2:NAVAL STATION MAYPORT - 280101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:410-507-6476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman