MEDICARE: WILSON ROVIRA PENA MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208800000X	Urology Physician	21095	PR

General Provider Information

NPI Number	:	1568758332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILSON ROVIRA PENA MD

Provider Business Mailing Address
First Line	:	PO BOX 601
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00681-0601
Country	:	US
Telephone Number	:	787-652-4205
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 CALLE DE DIEGO E
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00680-4863
Country	:	US
Telephone Number	:	787-652-4205
Fax Number	:	787-652-4206

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

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	10/10/2018

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