Provider Demographics
NPI:1407115835
Name:GONG, BO
Entity type:Individual
Prefix:MR
First Name:BO
Middle Name:
Last Name:GONG
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:ZHAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR JACK
Mailing Address - Street 1:2579 OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4946
Mailing Address - Country:US
Mailing Address - Phone:407-288-4865
Mailing Address - Fax:
Practice Address - Street 1:6559 N WICKHAM RD # C-103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2052
Practice Address - Country:US
Practice Address - Phone:407-861-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68483225700000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program