Healthcare Provider Details

I. General information

NPI: 1669506705
Provider Name (Legal Business Name): EDWIN PENG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

IV. Provider business mailing address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7679
  • Fax: 909-425-6635
Mailing address:
  • Phone: 909-425-7679
  • Fax: 909-425-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA69543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: