Provider Demographics
NPI:1417989799
Name:PENA, JANET MARIE (OD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:MARIE
Last Name:PENA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3926 HERRING DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-3174
Mailing Address - Country:US
Mailing Address - Phone:361-853-7466
Mailing Address - Fax:361-853-7467
Practice Address - Street 1:1821 S PADRE ISLAND DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78416-1398
Practice Address - Country:US
Practice Address - Phone:361-853-7466
Practice Address - Fax:361-853-7467
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6558T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0033FFOtherBCBS
TX170814101Medicaid
TX611419Medicare PIN
TX170814101Medicaid