Provider Demographics
NPI:1790048411
Name:PENA-DELGADO, MYRA ALEJANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:ALEJANDRA
Last Name:PENA-DELGADO
Suffix:
Gender:F
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:1001 WESTBANK DR
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6669
Practice Address - Country:US
Practice Address - Phone:512-654-4150
Practice Address - Fax:512-654-4151
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2047207Q00000X
NJ25MA09631700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX366393201Medicaid
TX366393201Medicaid