Provider Demographics
NPI:1215496260
Name:GONG, SAMUEL TOMMY
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:TOMMY
Last Name:GONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 S DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1216
Mailing Address - Country:US
Mailing Address - Phone:805-349-8514
Mailing Address - Fax:805-349-8958
Practice Address - Street 1:2271 S DEPOT ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1216
Practice Address - Country:US
Practice Address - Phone:805-349-8514
Practice Address - Fax:805-349-8958
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA176710207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine