Healthcare Provider Details

I. General information

NPI: 1639142680
Provider Name (Legal Business Name): RICARDO PENA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 VETERANS WAY
VIERA FL
32940-8007
US

IV. Provider business mailing address

93 DELANNOY AVE APT #606
COCOA FL
32922-7987
US

V. Phone/Fax

Practice location:
  • Phone: 321-637-3788
  • Fax: 321-637-3619
Mailing address:
  • Phone: 321-639-1159
  • Fax: 321-637-3619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0057462
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: