1386888709 NPI number — DR. CONSTANCE GONG M.D

Table of content: DR. CONSTANCE GONG M.D (NPI 1386888709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386888709 NPI number — DR. CONSTANCE GONG M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONG
Provider First Name:
CONSTANCE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1386888709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 BURNET AVE
Provider Second Line Business Mailing Address:
ML 2008
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45229-3026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-636-7966
Provider Business Mailing Address Fax Number:
513-636-7967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 BURNET AVE
Provider Second Line Business Practice Location Address:
ML 2008
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45229-3026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-636-7966
Provider Business Practice Location Address Fax Number:
513-636-7967
Provider Enumeration Date:
04/29/2009

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: 208000000X , with the licence number:  35.099604 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0204X , with the licence number: 35.099604 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 021853500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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