Provider Demographics
NPI:1710502695
Name:PENA, CAROL
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CAPRICORN ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-8106
Mailing Address - Country:US
Mailing Address - Phone:469-445-7053
Mailing Address - Fax:
Practice Address - Street 1:412 CAPRICORN ST
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-8106
Practice Address - Country:US
Practice Address - Phone:469-445-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2083P0901X2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine