Provider Demographics
NPI:1013280718
Name:PENG, KELLY CAROL (DO)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:CAROL
Last Name:PENG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MERCY CIRCLE
Mailing Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-719-3994
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-719-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-12
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203540207P00000X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine