Provider Demographics
NPI:1114747599
Name:GONG, QIANYU
Entity type:Individual
Prefix:
First Name:QIANYU
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21615 HUMMINGBIRD BUSH DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-0359
Mailing Address - Country:US
Mailing Address - Phone:646-717-1838
Mailing Address - Fax:
Practice Address - Street 1:8250 BELLAIRE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-4089
Practice Address - Country:US
Practice Address - Phone:713-777-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1159271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine