MEDICARE: MR. JUAN PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NN0400X	Neurology Chiropractor	111NN0400X	NY
2	213ES0103X	Foot & Ankle Surgery Podiatrist	213E00000X	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255733523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN PENA

Provider Business Mailing Address
First Line	:	1831 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-6323
Country	:	US
Telephone Number	:	718-365-6691
Fax Number	:	718-364-7777

Provider Business Practice Location Address
First Line	:	1831 GRAND CONCOURSE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-6323
Country	:	US
Telephone Number	:	718-365-6691
Fax Number	:	718-364-7777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	09/18/2014

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Directions to “ MR. JUAN PENA ” Practice Location

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