Provider Demographics
NPI:1831103779
Name:PEACE, DEVAUGHN (MD)
Entity Type:Individual
Prefix:
First Name:DEVAUGHN
Middle Name:
Last Name:PEACE
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 1:4326 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1648
Mailing Address - Country:US
Mailing Address - Phone:213-299-9914
Mailing Address - Fax:213-292-3254
Practice Address - Street 1:4326 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-1648
Practice Address - Country:US
Practice Address - Phone:213-299-9914
Practice Address - Fax:213-292-3254
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29868208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G298680Medicaid
CAG29868Medicare ID - Type UnspecifiedMEDICARE