Provider Demographics
NPI:1487098364
Name:PENA, LAURA E (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:EVELYN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:
Practice Address - Street 1:2550 BOBCAT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-5135
Practice Address - Country:US
Practice Address - Phone:817-347-8100
Practice Address - Fax:817-347-8099
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7456208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX359367501Medicaid
TX510868YKTUMedicare PIN