Provider Demographics
NPI:1154639771
Name:JI, PENG (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PENG
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E CHICAGO AVE
Mailing Address - Street 2:WARD 3-140
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4296
Mailing Address - Country:US
Mailing Address - Phone:617-901-5198
Mailing Address - Fax:
Practice Address - Street 1:420 E SUPERIOR ST
Practice Address - Street 2:RUBLOFF BUILDING 12-172
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4494
Practice Address - Country:US
Practice Address - Phone:312-503-4756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-058983207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology