Healthcare Provider Details

I. General information

NPI: 1902938988
Provider Name (Legal Business Name): CHUNG J PENG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLACKBERRY LN
NORTH CALDWELL NJ
07006-4170
US

IV. Provider business mailing address

1 BLACKBERRY LN
NORTH CALDWELL NJ
07006-4170
US

V. Phone/Fax

Practice location:
  • Phone: 973-429-6852
  • Fax:
Mailing address:
  • Phone: 973-429-6852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA04344900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: