Provider Demographics
NPI:1821282211
Name:PENA- JIMENEZ, AWILDA M (MD,)
Entity Type:Individual
Prefix:
First Name:AWILDA
Middle Name:M
Last Name:PENA- JIMENEZ
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:AWILDA
Other - Middle Name:M
Other - Last Name:PENA- JIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:7101 W MCNAB RD STE 101
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-5351
Practice Address - Country:US
Practice Address - Phone:954-722-5600
Practice Address - Fax:855-252-2845
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME107050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002818900Medicaid
FLFP2064373OtherDEA
FLFP2064373OtherDEA