Provider Demographics
NPI:1669483855
Name:PENA, DEOGRACIAS R (MD)
Entity Type:Individual
Prefix:
First Name:DEOGRACIAS
Middle Name:R
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 1:615 E PRINCETON ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1456
Mailing Address - Country:US
Mailing Address - Phone:407-303-9311
Mailing Address - Fax:407-303-9273
Practice Address - Street 1:615 E PRINCETON ST
Practice Address - Street 2:SUITE 401
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1456
Practice Address - Country:US
Practice Address - Phone:407-303-9311
Practice Address - Fax:407-303-9273
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ97782080P0210X
FLME563262080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1443501OtherUHC PIN
1750369203OtherGRP NPI NUMBER
TX10010075OtherAMERIGROUP PIN
TX5056081OtherAETNA PIN
TX75208965OtherCIGNA PIN
TX87Y112OtherBCBSTX PIN
TX109517OtherSUPERIOR PIN
TX121266102OtherFIRSTCARE PIN
TX133426012Medicaid
TX00U87ZOtherBCBSTX GRP PIN
TX1443501OtherUHC PIN
TX75208965OtherCIGNA PIN