Provider Demographics
NPI:1992867857
Name:PENA RUIZ, JORGE L I (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:PENA RUIZ
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PENA
Other - Middle Name:L
Other - Last Name:JORGE
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:URB.LAS SERRANIA
Mailing Address - Street 2:CALLE MADRIGAL #4
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-376-8930
Mailing Address - Fax:
Practice Address - Street 1:CALLE ARZUAGA #112 RIO PIEDRAS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925
Practice Address - Country:US
Practice Address - Phone:787-767-8758
Practice Address - Fax:844-759-2967
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1992867857208000000X
PR8626208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR37720900Medicaid
PR80393Medicaid