Provider Demographics
NPI:1770520306
Name:PENA, ROEHL (MD)
Entity type:Individual
Prefix:
First Name:ROEHL
Middle Name:
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 1:2345 E PRATER WAY STE 207
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-9634
Mailing Address - Country:US
Mailing Address - Phone:702-309-3360
Mailing Address - Fax:
Practice Address - Street 1:7280 W AZURE DR STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130
Practice Address - Country:US
Practice Address - Phone:702-309-3360
Practice Address - Fax:702-309-3370
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9935207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1770520306Medicaid
NV40384Medicare ID - Type Unspecified
NVH44236Medicare UPIN