Provider Demographics
NPI:1265744916
Name:DONOSO PENA, DANIELA M (MD)
Entity type:Individual
Prefix:
First Name:DANIELA
Middle Name:M
Last Name:DONOSO PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-1305
Mailing Address - Country:US
Mailing Address - Phone:712-623-7280
Mailing Address - Fax:
Practice Address - Street 1:1400 SENATE AVE STE 108
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1271
Practice Address - Country:US
Practice Address - Phone:712-623-7280
Practice Address - Fax:712-623-7279
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49963207R00000X
390200000X
IA47372207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ010721Medicaid
AZ010721Medicaid