Provider Demographics
NPI:1255303194
Name:PENG, JAMES CHUNG (M,D)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:CHUNG
Last Name:PENG
Suffix:
Gender:M
Credentials:M,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 N MAIN ST
Mailing Address - Street 2:P.O. BOX 489
Mailing Address - City:WINDHAM
Mailing Address - State:OH
Mailing Address - Zip Code:44288-1058
Mailing Address - Country:US
Mailing Address - Phone:330-326-3666
Mailing Address - Fax:
Practice Address - Street 1:9250 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:OH
Practice Address - Zip Code:44288-1058
Practice Address - Country:US
Practice Address - Phone:330-326-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-04
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.044522208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0440740Medicaid
OHPE0487582Medicare ID - Type Unspecified
OH0440740Medicaid