Provider Demographics
NPI:1154385599
Name:BONG, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:BONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:556 S FAIR OAKS AVE
Mailing Address - Street 2:#101-340
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2656
Mailing Address - Country:US
Mailing Address - Phone:626-390-7475
Mailing Address - Fax:
Practice Address - Street 1:23501 CINEMA DR
Practice Address - Street 2:SUITE 200
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5428
Practice Address - Country:US
Practice Address - Phone:661-288-4821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA626602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90522Medicare UPIN