Provider Demographics
NPI:1104817220
Name:PENA, JOSE OVIDIO JR (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:OVIDIO
Last Name:PENA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:415 ENCHANTED OAK DR
Mailing Address - Street 2:
Mailing Address - City:DRIFTWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78619-4221
Mailing Address - Country:US
Mailing Address - Phone:512-894-3694
Mailing Address - Fax:
Practice Address - Street 1:1301 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7533
Practice Address - Country:US
Practice Address - Phone:512-753-3796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5189207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8606M1Medicare PIN
TXF82247Medicare UPIN