Provider Demographics
NPI:1588628911
Name:GUEVARRA PENA, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:GUEVARRA PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GUEVARRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:14A JAYNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-475-0222
Mailing Address - Fax:631-475-4586
Practice Address - Street 1:14A JAYNE AVENUE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-475-0222
Practice Address - Fax:631-475-4586
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2095111207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
113660574OtherMAGNACARE
7121410OtherAETNA US HEALTHCARE PPO
180045562OtherRR RETIREMENT MEDICARE
3C3882OtherHEALTNET
000000082260OtherGHI HMO
0498205OtherGHI PPO
113660574OtherMULTIPLAN
2087772OtherFIRST HEALTH
3080739OtherAETNA US HEALTHCARE HMO
430A71OtherEMPIRE BLUE CROSS BLUE SH
AA72021OtherMDNY
P2807516OtherOXFORD
NY02315391Medicaid
1800045562OtherRR RETIREMENT MEDICARE
2095111OtherHIP
NY2095115WOtherWORKERS COMP
3818002003OtherCIGNA
2087772OtherFIRST HEALTH
P2807516OtherOXFORD