Provider Demographics
NPI:1316937535
Name:CHAN-PONG, KASENG DEREK (MD)
Entity type:Individual
Prefix:
First Name:KASENG
Middle Name:DEREK
Last Name:CHAN-PONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:K
Other - Middle Name:DEREK
Other - Last Name:CHAN-PONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5613
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR STE B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-952-2330
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73216207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49928YOtherMEDICARE
FL259780200Medicaid
F41778Medicare UPIN
FL259780200Medicaid