Provider Demographics
NPI:1255628640
Name:LI, PENG
Entity type:Individual
Prefix:
First Name:PENG
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD # 100275
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0301
Mailing Address - Country:US
Mailing Address - Phone:352-273-7839
Mailing Address - Fax:352-273-8172
Practice Address - Street 1:1600 SW ARCHER RD # 100275
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-7839
Practice Address - Fax:352-273-8172
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132726207ZH0000X, 207ZP0102X
UT8437499-1205207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021081500Medicaid
IZ523ZOtherMEDICARE PTAN