Provider Demographics
NPI:1154394781
Name:GONGLOFF, RICHARD K (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:K
Last Name:GONGLOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3436 WILLIAM PENN HWY
Mailing Address - Street 2:BUILDING 2, SUITE 166
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15235-5411
Mailing Address - Country:US
Mailing Address - Phone:412-823-6222
Mailing Address - Fax:
Practice Address - Street 1:3436 WILLIAM PENN HWY
Practice Address - Street 2:BUILDING 2, SUITE 166
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-5411
Practice Address - Country:US
Practice Address - Phone:412-823-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067474L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001754130Medicaid
PA001754130Medicaid
PA027562PD9Medicare ID - Type Unspecified