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General NPI Number Information
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NPI Number | 1477607240
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Entity Type | Organization
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Legal Business Name | H PENA MD NORTH MAIN MEDICAL AND SURGICAL CLINIC ASSOC
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3301 NORTH MAIN STREET
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City | FORT WORTH
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State | TX
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Zip | 76106
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Country | US
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Telephone | 817-625-2791
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Fax | 817-740-1550
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Provider Business Mailing Address
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Address Line | 3301 NORTH MAIN STREET
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City | FORT WORTH
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State | TX
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Zip | 76106
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Country | US
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Telephone | 817-625-2791
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Fax | 817-740-1550
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Authorized Official
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Title or Position | PRESIDENT
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Name | HERIBERTO PENA
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Credential | MD
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Telephone | 817-625-2791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | C7083
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License Number State | TX
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