Provider Demographics
NPI:1689607178
Name:PENG, VICKY (MD)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:PENG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 MONTGOMERY BLVD NE
Mailing Address - Street 2:STE 301
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1226
Mailing Address - Country:US
Mailing Address - Phone:505-727-4500
Mailing Address - Fax:505-727-4505
Practice Address - Street 1:4705 MONTGOMERY BLVD NE
Practice Address - Street 2:STE 301
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1226
Practice Address - Country:US
Practice Address - Phone:505-727-4500
Practice Address - Fax:505-727-4505
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM2001-280207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME6257Medicaid
NM485213YR41Medicare PIN
NME6257Medicaid