Provider Demographics
NPI:1922637966
Name:PENG, MAVIS SONG (MD)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:SONG
Last Name:PENG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ STE 7501
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1437
Practice Address - Country:US
Practice Address - Phone:310-267-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA185893208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA351356256015Medicaid