Provider Demographics
NPI:1144378167
Name:PENG, HENRY (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
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 1:624 W DUARTE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7603
Mailing Address - Country:US
Mailing Address - Phone:626-254-9540
Mailing Address - Fax:626-294-2996
Practice Address - Street 1:624 W DUARTE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7603
Practice Address - Country:US
Practice Address - Phone:626-254-9540
Practice Address - Fax:626-294-2996
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95408207Q00000X, 2084S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA95408OtherSTATE LICENSE