Provider Demographics
NPI:1033184130
Name:PENG, SHANE H (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:H
Last Name:PENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:400 SENTARA CIR
Mailing Address - Street 2:STE 450
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5716
Mailing Address - Country:US
Mailing Address - Phone:757-345-4614
Mailing Address - Fax:757-345-4601
Practice Address - Street 1:400 SENTARA CIR
Practice Address - Street 2:STE 450
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5716
Practice Address - Country:US
Practice Address - Phone:757-345-4614
Practice Address - Fax:757-345-4601
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101055813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010114284Medicaid
VA010114284Medicaid
G47554Medicare UPIN