Healthcare Provider Details

I. General information

NPI: 1962751784
Provider Name (Legal Business Name): CHULOU HITOSIS PENALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/27/2023
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13001 SOUTHERN BLVD
LOXAHATCHEE FL
33470-9203
US

IV. Provider business mailing address

5476 QUEENSHIP CT
GREENACRES FL
33463-5969
US

V. Phone/Fax

Practice location:
  • Phone: 877-832-2652
  • Fax: 800-792-9021
Mailing address:
  • Phone: 719-406-2133
  • Fax: 561-450-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 9295519
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP 9295519
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME163843
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: