Provider Demographics
NPI:1760502116
Name:PENA AYALA, ESTEBAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ESTEBAN
Middle Name:
Last Name:PENA AYALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ESTEBAN
Other - Middle Name:
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:810 E SANDIA HILLS DR
Mailing Address - Street 2:APT # 2208
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-2828
Mailing Address - Country:US
Mailing Address - Phone:404-519-5489
Mailing Address - Fax:404-519-5489
Practice Address - Street 1:9300 ALLEGIANCE ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4588
Practice Address - Country:US
Practice Address - Phone:404-519-5489
Practice Address - Fax:404-519-5489
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57011037207QA0505X
OH35.090444207R00000X
NMMD 2013-0215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPE4227893Medicare PIN