Provider Demographics
NPI:1417989799
Name:PENA, JANET MARIE (OD)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:MARIE
Last Name:PENA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 GRAND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5268
Mailing Address - Country:US
Mailing Address - Phone:361-658-8436
Mailing Address - Fax:
Practice Address - Street 1:1253 US HIGHWAY 181
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-1721
Practice Address - Country:US
Practice Address - Phone:361-643-1516
Practice Address - Fax:361-643-7479
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6558T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0033FFOtherBCBS
TX170814101Medicaid
TX611419Medicare PIN
TX170814101Medicaid