Provider Demographics
NPI:1710422662
Name:PENA, CARLOS EDWARDO
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:EDWARDO
Last Name:PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 W INTERSTATE HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2072
Mailing Address - Country:US
Mailing Address - Phone:956-580-0432
Mailing Address - Fax:
Practice Address - Street 1:8402 W INTERSTATE HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2072
Practice Address - Country:US
Practice Address - Phone:956-580-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32019553943Medicaid