Healthcare Provider Details

I. General information

NPI: 1568758332
Provider Name (Legal Business Name): WILSON ROVIRA PENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CALLE DE DIEGO E
MAYAGUEZ PR
00680-4863
US

IV. Provider business mailing address

PO BOX 601
MAYAGUEZ PR
00681-0601
US

V. Phone/Fax

Practice location:
  • Phone: 787-652-4205
  • Fax: 787-652-4206
Mailing address:
  • Phone: 787-652-4205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number21095
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: