MEDICARE: DR. SHANE H PENG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0101055813	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033184130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANE H PENG M.D.

Provider Business Mailing Address
First Line	:	400 SENTARA CIR
Second Line	:	STE 450
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-5716
Country	:	US
Telephone Number	:	757-345-4614
Fax Number	:	757-345-4601

Provider Business Practice Location Address
First Line	:	400 SENTARA CIR
Second Line	:	STE 450
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-5716
Country	:	US
Telephone Number	:	757-345-4614
Fax Number	:	757-345-4601

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	01/26/2012

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