Provider Demographics
NPI:1609862820
Name:PENG, ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
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 1:2725 MENDOCINO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2805
Mailing Address - Country:US
Mailing Address - Phone:707-542-6313
Mailing Address - Fax:075-456-7267
Practice Address - Street 1:2725 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2805
Practice Address - Country:US
Practice Address - Phone:707-545-4537
Practice Address - Fax:707-545-6726
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75807207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609862820Medicaid
CAP01774450OtherRAILROAD MEDICARE
CA1609862820Medicaid
CACA232710Medicare PIN
CACA230671Medicare PIN
CA00A758070Medicare ID - Type UnspecifiedMEDICARE