Provider Demographics
NPI:1699776138
Name:PENA, ANTONIO ALEXIS (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:ALEXIS
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 1:8600 SW 92ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7397
Mailing Address - Country:US
Mailing Address - Phone:305-596-5286
Mailing Address - Fax:305-596-5884
Practice Address - Street 1:8600 SW 92ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7397
Practice Address - Country:US
Practice Address - Phone:305-596-5286
Practice Address - Fax:305-596-5884
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL79481207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258196500Medicaid
FL258196500Medicaid
FLE5190Medicare ID - Type Unspecified