Healthcare Provider Details

I. General information

NPI: 1518923598
Provider Name (Legal Business Name): MICHELLE GUEVARRA PENA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14-A JAYNE AVENUE
PATCHOGUE NY
11772
US

IV. Provider business mailing address

14-A JAYNE AVENUE
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-0222
  • Fax: 631-475-4586
Mailing address:
  • Phone: 631-475-0222
  • Fax: 631-475-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MICHELLE GUEVARRA-PENA
Title or Position: SOLE MEMBER
Credential: MD
Phone: 631-475-0222