Healthcare Provider Details

I. General information

NPI: 1154391977
Provider Name (Legal Business Name): JOSE CALIXTO DE LA PENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5722 INTERGRITY DR. BLGD S771 (NBHC MIDSOUTH
MILLINGTON TN
38054
US

IV. Provider business mailing address

4566 NOB HILL DR.
ARLINGTON TN
38002-5150
US

V. Phone/Fax

Practice location:
  • Phone: 901-874-6143
  • Fax:
Mailing address:
  • Phone: 901-249-7356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00053436
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: