Provider Demographics
NPI:1093937112
Name:CHONG, PENNY JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:JEAN
Last Name:CHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29525 CANWOOD ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4233
Mailing Address - Country:US
Mailing Address - Phone:818-781-5195
Mailing Address - Fax:
Practice Address - Street 1:29525 CANWOOD ST
Practice Address - Street 2:SUITE 205
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4233
Practice Address - Country:US
Practice Address - Phone:818-781-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53507207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02735Medicare UPIN