MEDICARE: DR. CERVANTES B 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	208000000X	Pediatrics Physician	266996	NY

General Provider Information

NPI Number	:	1376538553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CERVANTES B PENA M.D

Provider Business Mailing Address
First Line	:	10211 ROOSEVELT AVE
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-2331
Country	:	US
Telephone Number	:	718-898-5200
Fax Number	:	718-898-3673

Provider Business Practice Location Address
First Line	:	10211 ROOSEVELT AVE
Second Line	:
City	:	CORONA
State	:	NY
Zip	:	11368-2331
Country	:	US
Telephone Number	:	718-898-5200
Fax Number	:	718-898-3673

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	10/18/2012

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