Provider Demographics
NPI:1841480381
Name:GUILLERMO A PENA MD PA
Entity type:Organization
Organization Name:GUILLERMO A PENA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-363-4666
Mailing Address - Street 1:1435 W 49TH PL
Mailing Address - Street 2:SUITE # 403
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3197
Mailing Address - Country:US
Mailing Address - Phone:305-362-4666
Mailing Address - Fax:305-362-4679
Practice Address - Street 1:1435 W 49TH PL
Practice Address - Street 2:SUITE # 403
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3197
Practice Address - Country:US
Practice Address - Phone:305-362-4666
Practice Address - Fax:305-362-4679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 46222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD63954Medicare UPIN