Provider Demographics
NPI:1104801463
Name:FAN, PENG THIM (MD)
Entity type:Individual
Prefix:DR
First Name:PENG
Middle Name:THIM
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12660 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3430
Mailing Address - Country:US
Mailing Address - Phone:818-980-7010
Mailing Address - Fax:818-980-7330
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3430
Practice Address - Country:US
Practice Address - Phone:818-980-7010
Practice Address - Fax:818-980-7330
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24140Medicare UPIN