Provider Demographics
NPI:1760502116
Name:PENA AYALA, ESTEBAN (MD)
Entity type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:
Last Name:PENA AYALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ESTEBAN
Other - Middle Name:
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9311 S REDHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3057
Mailing Address - Country:US
Mailing Address - Phone:404-519-5489
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:404-519-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57011037207QA0505X
OH35.090444207R00000X
NCPENA-KJSY7U390200000X
NMMD 2013-0215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPE4227893Medicare PIN