Provider Demographics
NPI:1700841152
Name:PENA, ELPIDIO DEJESUS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELPIDIO
Middle Name:DEJESUS
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 1:2307 GREENE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-4009
Mailing Address - Country:US
Mailing Address - Phone:502-897-9594
Mailing Address - Fax:
Practice Address - Street 1:2307 GREENE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4009
Practice Address - Country:US
Practice Address - Phone:502-897-9594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36832207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64039423Medicaid
0679420Medicare ID - Type Unspecified
KY64039423Medicaid