Provider Demographics
NPI:1487180964
Name:GONG, PAUL H (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:H
Last Name:GONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3999 DUTCHMANS LN STE 5D
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4744
Practice Address - Country:US
Practice Address - Phone:502-899-6782
Practice Address - Fax:502-540-7268
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY592992084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program