Healthcare Provider Details

I. General information

NPI: 1619149762
Provider Name (Legal Business Name): OMAR JOSE PENA LOPEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 SOUTH BROADWAY
ELSA TX
78543-0000
US

IV. Provider business mailing address

410 SOUTH BROADWAY
ELSA TX
78543-0000
US

V. Phone/Fax

Practice location:
  • Phone: 956-262-9805
  • Fax: 956-262-9233
Mailing address:
  • Phone: 956-262-9805
  • Fax: 956-262-9233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN1058
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: