Provider Demographics
NPI:1912327677
Name:PENA DIAZ, ROBERT VINCENT (MSED)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:VINCENT
Last Name:PENA DIAZ
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 77TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1151
Mailing Address - Country:US
Mailing Address - Phone:347-585-6005
Mailing Address - Fax:
Practice Address - Street 1:3915 62ND ST APT 42
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3612
Practice Address - Country:US
Practice Address - Phone:347-585-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist