Healthcare Provider Details

I. General information

NPI: 1831103779
Provider Name (Legal Business Name): DEVAUGHN PEACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4326 S WESTERN AVE
LOS ANGELES CA
90062-1648
US

IV. Provider business mailing address

4326 S WESTERN AVE
LOS ANGELES CA
90062-1648
US

V. Phone/Fax

Practice location:
  • Phone: 213-299-9914
  • Fax: 213-292-3254
Mailing address:
  • Phone: 213-299-9914
  • Fax: 213-292-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG29868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: