Provider Demographics
NPI:1063701274
Name:PENA, EMMANUEL (DO)
Entity type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 1130
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8329
Mailing Address - Country:US
Mailing Address - Phone:904-603-4199
Mailing Address - Fax:904-633-4188
Practice Address - Street 1:841 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1130
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-603-4199
Practice Address - Fax:904-633-4188
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12734208000000X, 2080C0008X
WY11096A208000000X
GA11096A208000000X
GA806222080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics