Provider Demographics
NPI:1982182184
Name:DE LA PENA MIR, RUBENS SR (MSN)
Entity Type:Individual
Prefix:DR
First Name:RUBENS
Middle Name:
Last Name:DE LA PENA MIR
Suffix:SR
Gender:M
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12820 SW 43RD DR APT 227B
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4152
Mailing Address - Country:US
Mailing Address - Phone:786-970-2112
Mailing Address - Fax:
Practice Address - Street 1:12820 SW 43RD DR APT 227B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-4152
Practice Address - Country:US
Practice Address - Phone:786-970-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9401713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty