Healthcare Provider Details

I. General information

NPI: 1265792501
Provider Name (Legal Business Name): LEI PENG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR STE 765
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-1717
  • Fax: 571-472-1718
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberD84351
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberD84351
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number0101281832
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: