Provider Demographics
NPI:1104920859
Name:PENALO, PEDRO J (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:J
Last Name:PENALO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1145
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78599
Mailing Address - Country:US
Mailing Address - Phone:956-447-8600
Mailing Address - Fax:956-447-0335
Practice Address - Street 1:906 S BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596
Practice Address - Country:US
Practice Address - Phone:956-447-8600
Practice Address - Fax:956-447-0335
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173357802Medicaid
TX173357802Medicaid
TX612893Medicare PIN