Provider Demographics
NPI:1194703009
Name:GONGWER, MELODY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:MELODY
Middle Name:ANN
Last Name:GONGWER
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 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2259
Practice Address - Street 1:1315 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3023
Practice Address - Country:US
Practice Address - Phone:812-279-3591
Practice Address - Fax:812-275-0787
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051287A2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200264440AMedicaid
000000192710OtherANTHEM PIN
IN562950WMedicare ID - Type Unspecified
INF64483Medicare UPIN
IN200264440AMedicaid