Provider Demographics
NPI:1275597304
Name:PENA, RICHARD CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
Last Name:PENA
Suffix:
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 1:1607 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5619
Mailing Address - Country:US
Mailing Address - Phone:940-767-5581
Mailing Address - Fax:940-767-0046
Practice Address - Street 1:1607 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5619
Practice Address - Country:US
Practice Address - Phone:940-767-5581
Practice Address - Fax:940-767-0046
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1895207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1828790-01Medicaid
GADN4511OtherRAILROAD MEDICARE
TXF1895Medicare UPIN
GADN4511OtherRAILROAD MEDICARE