Healthcare Provider Details

I. General information

NPI: 1063701274
Provider Name (Legal Business Name): EMMANUEL PENA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR SUITE 1130
JACKSONVILLE FL
32207
US

IV. Provider business mailing address

841 PRUDENTIAL DR SUITE 1130
JACKSONVILLE FL
32207-8329
US

V. Phone/Fax

Practice location:
  • Phone: 904-603-4199
  • Fax: 904-633-4188
Mailing address:
  • Phone: 904-603-4199
  • Fax: 904-633-4188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS12734
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11096A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11096A
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberOS12734
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number80622
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: