MEDICARE: JULIO ERNESTO PENA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	75119	GA

General Provider Information

NPI Number	:	1073891198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIO ERNESTO PENA M.D.

Provider Business Mailing Address
First Line	:	1360 CADUCEUS WAY
Second Line	:	BLDG 400, SUITE 104
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-7300
Country	:	US
Telephone Number	:	706-850-8135
Fax Number	:	706-548-9101

Provider Business Practice Location Address
First Line	:	1360 CADUCEUS WAY
Second Line	:	BLDG 400, SUITE 104
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-7300
Country	:	US
Telephone Number	:	706-850-8135
Fax Number	:	706-548-9101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2011
Last Update Date	:	07/18/2016

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