Provider Demographics
NPI:1447350194
Name:PENA, CARLOS G (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:G
Last Name:PENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 SW 57TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3638
Mailing Address - Country:US
Mailing Address - Phone:786-514-6395
Mailing Address - Fax:786-615-4456
Practice Address - Street 1:6705 SW 57TH AVE STE 310
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3638
Practice Address - Country:US
Practice Address - Phone:786-514-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96839174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPPLIED FORMedicaid
FLBC BS OF FLORIDAOtherAPPLICATION IN PROCESS
FLAPPLIED FORMedicaid