Basic Information
| Provider Information | |||||||||
| NPI: | 1881650398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY | ||||||||
| Address2: | STE 35 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610333 | ||||||||
| FaxNumber: | 8067857685 | ||||||||
| Practice Location | |||||||||
| Address1: | 7501 QUAKER AVE | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794243367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067883306 | ||||||||
| FaxNumber: | 8067223861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E8810 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 137508106 | 05 | TX | MEDICAID |