Provider Demographics
NPI:1619149762
Name:PENA LOPEZ, OMAR JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:JOSE
Last Name:PENA LOPEZ
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 1:410 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELSA
Mailing Address - State:TX
Mailing Address - Zip Code:78543-0000
Mailing Address - Country:US
Mailing Address - Phone:956-262-9805
Mailing Address - Fax:956-262-9233
Practice Address - Street 1:410 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:ELSA
Practice Address - State:TX
Practice Address - Zip Code:78543-0000
Practice Address - Country:US
Practice Address - Phone:956-262-9805
Practice Address - Fax:956-262-9233
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201687501Medicaid