Provider Demographics
NPI:1639142680
Name:PENA, RICARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name: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 1:93 DELANNOY AVE
Mailing Address - Street 2:APT #606
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7987
Mailing Address - Country:US
Mailing Address - Phone:321-639-1159
Mailing Address - Fax:321-637-3619
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:321-637-3619
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0057462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17718YMedicare ID - Type UnspecifiedPROVIDER NUMBER