Provider Demographics
NPI:1841857166
Name:PENA, DOMINGO (MD)
Entity type:Individual
Prefix:
First Name:DOMINGO
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 1:80 HAVEN AVE APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2615
Mailing Address - Country:US
Mailing Address - Phone:718-501-2689
Mailing Address - Fax:917-471-8032
Practice Address - Street 1:1150 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-5205
Practice Address - Country:US
Practice Address - Phone:718-975-1044
Practice Address - Fax:917-471-8032
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY319216207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program