Provider Demographics
NPI:1851928121
Name:PENALOZA PACHECO, JUAN FIDEL (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:FIDEL
Last Name:PENALOZA PACHECO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:FIDEL
Other - Last Name:PENALOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10535 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655-4200
Mailing Address - Country:US
Mailing Address - Phone:916-734-7058
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-734-7058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178289207R00000X, 390200000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program