1770697112 NPI number — DR. MARLENE PENG MD

Table of content: DR. MARLENE PENG MD (NPI 1770697112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770697112 NPI number — DR. MARLENE PENG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENG
Provider First Name:
MARLENE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770697112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 MINOR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-386-9500
Provider Business Mailing Address Fax Number:
206-576-3802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 MINOR AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98104-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-386-9500
Provider Business Practice Location Address Fax Number:
206-576-3802
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  MD60102678 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207K00000X , with the licence number: 68453341205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0201X , with the licence number: 46653 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 256768 . This is a "LNI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8560427 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0024PE . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 34622400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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