Provider Demographics
NPI:1346276789
Name:CHONG, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CHONG
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 1:15446 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4319
Mailing Address - Country:US
Mailing Address - Phone:310-217-5470
Mailing Address - Fax:310-217-5343
Practice Address - Street 1:15446 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4319
Practice Address - Country:US
Practice Address - Phone:310-217-5470
Practice Address - Fax:310-217-5343
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100103OtherHPK
KS100232700AMedicaid
KS16837OtherCOVENTRY
KS12084355OtherMULTIPLAN
KS2570OtherPHS
KS014467Medicare ID - Type Unspecified