Provider Demographics
NPI:1336257567
Name:PENG, WENG (MD)
Entity Type:Individual
Prefix:MR
First Name:WENG
Middle Name:
Last Name:PENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3641 RIDGE ROAD
Mailing Address - Street 2:SUITE #5
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322
Mailing Address - Country:US
Mailing Address - Phone:219-972-3811
Mailing Address - Fax:219-972-3844
Practice Address - Street 1:3641 RIDGE ROAD
Practice Address - Street 2:SUITE #5
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322
Practice Address - Country:US
Practice Address - Phone:219-972-3811
Practice Address - Fax:219-972-3844
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035904A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093656OtherBCBS
141450Medicare ID - Type Unspecified
B29324Medicare UPIN