Provider Demographics
NPI:1780643692
Name:DE LA PENA, OCTAVIO A (MD)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:A
Last Name:DE LA PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7610 STEMMONS FWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4231
Mailing Address - Country:US
Mailing Address - Phone:214-689-5960
Mailing Address - Fax:214-630-7293
Practice Address - Street 1:4401 COIT RD
Practice Address - Street 2:SITE 201
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-0500
Practice Address - Country:US
Practice Address - Phone:972-335-7306
Practice Address - Fax:972-335-7468
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2010-05-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXK3150207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142704901Medicaid
TX8B4310OtherBCBSTX
TX102131303Medicaid
TX8012N0Medicare PIN
TX8B4310OtherBCBSTX
TXG46510Medicare UPIN