Provider Demographics
NPI:1467688960
Name:PENA, JEREMY RYAN A (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JEREMY RYAN
Middle Name:A
Last Name:PENA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT STREET
Mailing Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-726-0967
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-0967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-240308207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology