Provider Demographics
NPI:1255496709
Name:PENA, PORFIRIO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PORFIRIO
Middle Name:
Last Name:PENA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 NE HOYT ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2991
Mailing Address - Country:US
Mailing Address - Phone:503-230-9224
Mailing Address - Fax:503-230-9201
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-230-9224
Practice Address - Fax:503-230-9201
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000810Medicaid
OR000810Medicaid
OR139215Medicare PIN