Provider Demographics
NPI:1861554552
Name:PENA, KRISTIN SUZANNE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:SUZANNE
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:138 W MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-2584
Practice Address - Country:US
Practice Address - Phone:805-667-2850
Practice Address - Fax:805-652-0708
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0897OSSMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
CAH29008Medicare UPIN