Provider Demographics
NPI:1003410747
Name:PENG, XIAOBO (MD)
Entity Type:Individual
Prefix:MR
First Name:XIAOBO
Middle Name:
Last Name:PENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12828 MACBETH FARM LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1555
Mailing Address - Country:US
Mailing Address - Phone:240-714-8569
Mailing Address - Fax:
Practice Address - Street 1:414 HUNGERFORD DR STE 200
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-4125
Practice Address - Country:US
Practice Address - Phone:240-714-8569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02776171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU02776OtherSTATE BOARD OF ACUPUNCTURE
MDP520928001757OtherDRIVER LICENSE