Provider Demographics
NPI:1316949787
Name:126TH STREET MEDICAL
Entity type:Organization
Organization Name:126TH STREET MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-250-8000
Mailing Address - Street 1:12601 D COASTAL HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9784
Mailing Address - Country:US
Mailing Address - Phone:410-250-8000
Mailing Address - Fax:410-250-1308
Practice Address - Street 1:12601 D COASTAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9784
Practice Address - Country:US
Practice Address - Phone:410-250-8000
Practice Address - Fax:410-250-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD345LMedicare ID - Type Unspecified