Basic Information
| Provider Information | |||||||||
| NPI: | 1255628640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | PENG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1600 SW ARCHER RD # 100275 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737839 | ||||||||
| FaxNumber: | 3522738172 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD # 100275 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737839 | ||||||||
| FaxNumber: | 3522738172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZH0000X | ME132726 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | ME132726 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZH0000X | 8437499-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pathology | Hematology |
ID Information
| ID | Type | State | Issuer | Description | 021081500 | 05 | FL | MEDICAID | IZ523Z | 01 | MEDICARE PTAN | OTHER |