Healthcare Provider Details

I. General information

NPI: 1760502116
Provider Name (Legal Business Name): ESTEBAN PENA AYALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ESTEBAN PENA M.D.

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 04/27/2024
Certification Date: 04/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

9311 S REDHAVEN DR
SANDY UT
84094-3057
US

V. Phone/Fax

Practice location:
  • Phone: 404-519-5489
  • Fax:
Mailing address:
  • Phone: 404-519-5489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number57011037
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.090444
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPENA-KJSY7U
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD 2013-0215
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: