Provider Demographics
NPI:1467533943
Name:ESTIANDAN, CARLOS PENA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:PENA
Last Name:ESTIANDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAN ANTONIO
Other - Middle Name:
Other - Last Name:HEALTH CARE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17756 SATICOY ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3381
Mailing Address - Country:US
Mailing Address - Phone:818-757-3068
Mailing Address - Fax:818-757-7594
Practice Address - Street 1:17756 SATICOY ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3381
Practice Address - Country:US
Practice Address - Phone:818-757-3068
Practice Address - Fax:818-757-7594
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38326207Q00000X, 207R00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13046Medicare ID - Type Unspecified
A85122Medicare UPIN