Provider Demographics
NPI: | 1548586688 |
---|---|
Name: | CARLOS G. PENA MD PA |
Entity Type: | Organization |
Organization Name: | CARLOS G. PENA MD PA |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | VANESSA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BENTLEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 305-271-5533 |
Mailing Address - Street 1: | 8940 N KENDALL DR |
Mailing Address - Street 2: | SUITE 701E |
Mailing Address - City: | MIAMI |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33176-2148 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 305-271-5533 |
Mailing Address - Fax: | 786-220-9314 |
Practice Address - Street 1: | 8940 N KENDALL DR |
Practice Address - Street 2: | SUITE 701E |
Practice Address - City: | MIAMI |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33176-2148 |
Practice Address - Country: | US |
Practice Address - Phone: | 305-271-5533 |
Practice Address - Fax: | 786-220-9314 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-04-14 |
Last Update Date: | 2010-04-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME96839 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Multi-Specialty |