Provider Demographics
NPI:1033305677
Name:PENG, HAI EN (DPM)
Entity Type:Individual
Prefix:DR
First Name:HAI
Middle Name:EN
Last Name:PENG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2460 N PONDEROSA DR
Mailing Address - Street 2:STE A105
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2375
Mailing Address - Country:US
Mailing Address - Phone:805-482-0711
Mailing Address - Fax:805-482-6524
Practice Address - Street 1:2460 N PONDEROSA DR
Practice Address - Street 2:STE A105
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2375
Practice Address - Country:US
Practice Address - Phone:805-482-0711
Practice Address - Fax:805-482-6524
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4368213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43680Medicaid
CA000E43680Medicaid
CAE4368Medicare PIN