MEDICARE: DEVAUGHN PEACE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	G29868	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831103779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVAUGHN PEACE MD

Provider Business Mailing Address
First Line	:	4326 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90062-1648
Country	:	US
Telephone Number	:	213-299-9914
Fax Number	:	213-292-3254

Provider Business Practice Location Address
First Line	:	4326 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90062-1648
Country	:	US
Telephone Number	:	213-299-9914
Fax Number	:	213-292-3254

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/09/2007

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