Provider Demographics
NPI:1871859744
Name:OMAR J PENA LOPEZ MD PA
Entity Type:Organization
Organization Name:OMAR J PENA LOPEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENA LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-971-8100
Mailing Address - Street 1:1403 CARNELIAN DR
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-4388
Mailing Address - Country:US
Mailing Address - Phone:956-971-8100
Mailing Address - Fax:956-971-8102
Practice Address - Street 1:200 W. EDINBURG HWY 107
Practice Address - Street 2:
Practice Address - City:ELSA
Practice Address - State:TX
Practice Address - Zip Code:78543
Practice Address - Country:US
Practice Address - Phone:956-262-9805
Practice Address - Fax:956-971-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154255701Medicaid
TX1619149762OtherNPI INDIVIDUAL