Provider Demographics
NPI:1366732604
Name:PENA, MICHAEL R (MD PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:PENA
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-4547
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-4547
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE26460207Q00000X
SD8607207Q00000X
PAMD443240207Q00000X
NMMD2017-0882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine