Provider Demographics
NPI:1790784007
Name:PENA, PEDRO (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16550-0002
Mailing Address - Country:US
Mailing Address - Phone:814-877-6182
Mailing Address - Fax:814-877-6149
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-6182
Practice Address - Fax:814-877-6149
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015257E2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1068921OtherW. VIRGINIA WORKERS COMP
PA300120916OtherRR MEDICARE
NY00025445602OtherUNIVERA
PA1521688OtherGATEWAY
PA0018379020003Medicaid
NY02146761OtherNY MEDICAL ASSISTANCE
OH2231365OtherOH MEDICAL ASSISTANCE
PA3369068OtherAETNA
PA304576OtherUPMC
PA118180OtherUNISON
PA722913OtherBLUE SHIELD
PA044256E7CMedicare PIN
PA300120916OtherRR MEDICARE