Provider Demographics
NPI:1992801583
Name:PENA CARDENAS, TIRSO T
Entity type:Individual
Prefix:
First Name:TIRSO
Middle Name:T
Last Name:PENA CARDENAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 AVE LAS AMERICAS
Mailing Address - Street 2:STE 212 EDIFICIO PORRATA PILA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-2113
Mailing Address - Country:US
Mailing Address - Phone:787-848-8001
Mailing Address - Fax:787-848-8001
Practice Address - Street 1:2431 AVE LAS AMERICAS
Practice Address - Street 2:STE 212 EDIFICIO PORRATA PILA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2113
Practice Address - Country:US
Practice Address - Phone:787-848-8001
Practice Address - Fax:787-848-8001
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG40949Medicare UPIN
PR0084423Medicare ID - Type Unspecified