Provider Demographics
NPI:1063622819
Name:PENA-RUIZ, MIGUEL ANGEL (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:PENA-RUIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MIGUEL
Other - Middle Name:A
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4650 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8404
Mailing Address - Country:US
Mailing Address - Phone:619-662-5013
Mailing Address - Fax:619-662-5017
Practice Address - Street 1:4650 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-8404
Practice Address - Country:US
Practice Address - Phone:619-662-5013
Practice Address - Fax:619-662-5017
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10021613207R00000X
CAA101128207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine