Provider Demographics
NPI:1720163751
Name:YEN, PEDRO (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:YEN
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 1:4137 WALNUT GLEN PL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-6271
Mailing Address - Country:US
Mailing Address - Phone:214-366-3796
Mailing Address - Fax:
Practice Address - Street 1:1900 OATES DR
Practice Address - Street 2:SUITE 138
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6862
Practice Address - Country:US
Practice Address - Phone:972-270-7600
Practice Address - Fax:972-270-9968
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1958207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092097701Medicaid
TX092097701Medicaid
TX0088AGMedicare UPIN