Provider Demographics
NPI:1093556185
Name:PENA, ROGELIO (RD)
Entity type:Individual
Prefix:
First Name:ROGELIO
Middle Name:
Last Name:PENA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 W 7TH PL
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-4622
Mailing Address - Country:US
Mailing Address - Phone:480-280-4414
Mailing Address - Fax:
Practice Address - Street 1:1511 W 7TH PL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-4622
Practice Address - Country:US
Practice Address - Phone:480-280-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ980531133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered