Provider Demographics
NPI:1215982855
Name:GONG, HENRY P (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:P
Last Name:GONG
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2220 GLADSTONE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-5123
Mailing Address - Country:US
Mailing Address - Phone:925-432-3318
Mailing Address - Fax:
Practice Address - Street 1:2220 GLADSTONE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5123
Practice Address - Country:US
Practice Address - Phone:925-432-3318
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG43569207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G435690Medicaid
CAA49395Medicare UPIN