Provider Demographics
NPI:1366451759
Name:PENA, ROBERTO M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:M
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:900 E 30TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-3326
Mailing Address - Country:US
Mailing Address - Phone:512-477-4693
Mailing Address - Fax:512-477-2160
Practice Address - Street 1:900 E 30TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-3326
Practice Address - Country:US
Practice Address - Phone:512-477-4693
Practice Address - Fax:512-477-2160
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG3051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00F76ROtherBC/BS PROVIDER NUMBER
TXD67534Medicare UPIN