Basic Information
Provider Information
NPI: 1033559455
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PENA
FirstName: DAMARIS
MiddleName: ELIXANDRA
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1650 GRAND CONCOURSE
Address2:  
City: BRONX
State: NY
PostalCode: 104577606
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1650 GRAND CONCOURSE
Address2:  
City: BRONX
State: NY
PostalCode: 104577606
CountryCode: US
TelephoneNumber: 7189601234
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/29/2013
LastUpdateDate: 06/29/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X NYY Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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