Healthcare Provider Details

I. General information

NPI: 1144378167
Provider Name (Legal Business Name): HENRY PENG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W DUARTE RD SUITE 102
ARCADIA CA
91007-7603
US

IV. Provider business mailing address

624 W DUARTE RD SUITE 102
ARCADIA CA
91007-7603
US

V. Phone/Fax

Practice location:
  • Phone: 626-254-9540
  • Fax: 626-294-2996
Mailing address:
  • Phone: 626-254-9540
  • Fax: 626-294-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA95408
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084S0010X
TaxonomySports Medicine (Psychiatry & Neurology) Physician
License NumberA95408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: