Basic Information
| Provider Information | |||||||||
| NPI: | 1063701274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | EMMANUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 841 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1130 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046034199 | ||||||||
| FaxNumber: | 9046334188 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1130 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046034199 | ||||||||
| FaxNumber: | 9046334188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS12734 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 11096A | WY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 11096A | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080C0008X | OS12734 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics | 2080C0008X | 80622 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics |
No ID Information.