Provider Demographics
NPI:1477607240
Name:H PENA MD NORTH MAIN MEDICAL AND SURGICAL CLINIC ASSOC
Entity Type:Organization
Organization Name:H PENA MD NORTH MAIN MEDICAL AND SURGICAL CLINIC ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERIBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-625-2791
Mailing Address - Street 1:3301 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76106
Mailing Address - Country:US
Mailing Address - Phone:817-625-2791
Mailing Address - Fax:817-740-1550
Practice Address - Street 1:3301 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76106
Practice Address - Country:US
Practice Address - Phone:817-625-2791
Practice Address - Fax:817-740-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC7083208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty