Provider Demographics
NPI:1831715275
Name:PENG, GISELLE
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:PENG
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 1:3800 RESERVOIR RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2113
Mailing Address - Country:US
Mailing Address - Phone:469-231-6648
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-444-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2024-04-25
Deactivation Date:2024-03-25
Deactivation Code:
Reactivation Date:2024-04-13
Provider Licenses
StateLicense IDTaxonomies
DCMTL500002413208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery