Basic Information
| Provider Information | |||||||||
| NPI: | 1265540462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONG | ||||||||
| FirstName: | MERRY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 SACRAMENTO ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947022739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106016060 | ||||||||
| FaxNumber: | 5104284594 | ||||||||
| Practice Location | |||||||||
| Address1: | 2344 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947102412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109813203 | ||||||||
| FaxNumber: | 5105532169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 03/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | G32302 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ89670Z | 01 | CA | PTAN | OTHER | 00G323020 | 05 | CA | MEDICAID |