Healthcare Provider Details

I. General information

NPI: 1912956384
Provider Name (Legal Business Name): EDUARDO IGNACIO PENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 N MILITARY TRL
RIVIERA BEACH FL
33410-7417
US

IV. Provider business mailing address

1408 N KILLIAN DR SUITE 112
WEST PALM BEACH FL
33403-1962
US

V. Phone/Fax

Practice location:
  • Phone: 561-422-8262
  • Fax:
Mailing address:
  • Phone: 561-307-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberME0073030
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME0073030
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberME0073030
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME0073030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: