Basic Information
| Provider Information | |||||||||
| NPI: | 1902520166 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTOR GONG INTERNAL MEDICINE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | DEMAREST | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076272715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052862 | ||||||||
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| Practice Location | |||||||||
| Address1: | 68 HOLLAND AVE | ||||||||
| Address2: | |||||||||
| City: | DEMAREST | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076272715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052862 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2022 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | GONG | ||||||||
| AuthorizedOfficialFirstName: | BING | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2016583148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.