Provider Demographics
NPI:1194091660
Name:GAN, QIONG (MD)
Entity type:Individual
Prefix:
First Name:QIONG
Middle Name:
Last Name:GAN
Suffix:
Gender:F
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:P O BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6398207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393934001Medicaid
TX393934002OtherCSHCN (MEDICAID)
TX8KB008OtherBCBS