Healthcare Provider Details

I. General information

NPI: 1245556653
Provider Name (Legal Business Name): KEVIN ALBERT PENG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W 3RD ST STE 111
LOS ANGELES CA
90057-1999
US

IV. Provider business mailing address

2100 W 3RD ST STE 111
LOS ANGELES CA
90057-1999
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9930
  • Fax: 213-784-5406
Mailing address:
  • Phone: 213-483-9930
  • Fax: 213-784-5406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberA120366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: