Provider Demographics
NPI:1982834347
Name:PENERA, KEITH E (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:PENERA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19066 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-2232
Mailing Address - Country:US
Mailing Address - Phone:714-968-0068
Mailing Address - Fax:
Practice Address - Street 1:19066 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2232
Practice Address - Country:US
Practice Address - Phone:714-968-0068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEL1784213E00000X
CAE4975213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist