Provider Demographics
NPI:1013978162
Name:PENA, GUILLERMO A (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:A
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BLUE RIDGE OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4431
Mailing Address - Country:US
Mailing Address - Phone:706-946-5608
Mailing Address - Fax:706-374-7628
Practice Address - Street 1:165 BLUE RIDGE OVERLOOK
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4431
Practice Address - Country:US
Practice Address - Phone:706-946-4647
Practice Address - Fax:706-374-5006
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL46222207R00000X
GA059493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA297695058AMedicaid
FL040614700Medicaid
GA297695058AMedicaid