Provider Demographics
NPI:1740352566
Name:PENA, ANDRES (MD)
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDRES
Other - Middle Name:
Other - Last Name:PENA-CIFUENTES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6555 COYLE AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0302
Mailing Address - Country:US
Mailing Address - Phone:916-536-2408
Mailing Address - Fax:
Practice Address - Street 1:6555 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0302
Practice Address - Country:US
Practice Address - Phone:916-536-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86087208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A860870Medicaid
00A860870Medicare ID - Type Unspecified
CA00A860870Medicaid