=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780911586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARITZA DEL PILAR DE LA PENA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2009
-----------------------------------------------------
Last Update Date | 09/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72780 COUNTRY CLUB DR STE 305C
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-4149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-837-8748
-----------------------------------------------------
Fax | 760-837-8749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39000 BOB HOPE DR
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-3221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-837-8748
-----------------------------------------------------
Fax | 760-837-8749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | C162153
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | C162153
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------