Provider Demographics
NPI:1568758332
Name:ROVIRA PENA, WILSON (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:ROVIRA PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0601
Mailing Address - Country:US
Mailing Address - Phone:787-652-4205
Mailing Address - Fax:
Practice Address - Street 1:103 CALLE DE DIEGO E
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4863
Practice Address - Country:US
Practice Address - Phone:787-652-4205
Practice Address - Fax:787-652-4206
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR21095208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program