Provider Demographics
NPI:1386138030
Name:PENA, EMILIO MIGUEL (MD)
Entity type:Individual
Prefix:
First Name:EMILIO
Middle Name:MIGUEL
Last Name:PENA
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:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:
Practice Address - Street 1:11100 SUMMER RIDGE LANE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3289
Practice Address - Country:US
Practice Address - Phone:239-344-2307
Practice Address - Fax:239-267-6219
Is Sole Proprietor?:No
Enumeration Date:2018-06-17
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150763208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics