Provider Demographics
NPI:1588696637
Name:GONG, YINJIA (MD)
Entity type:Individual
Prefix:DR
First Name:YINJIA
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YINJIA ROSE
Other - Middle Name:
Other - Last Name:GONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1520 BROOKHOLLOW DR STE 36
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5427
Mailing Address - Country:US
Mailing Address - Phone:714-881-7081
Mailing Address - Fax:
Practice Address - Street 1:1520 BROOKHOLLOW DR STE 36
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5427
Practice Address - Country:US
Practice Address - Phone:714-881-7081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0A56519204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A565190Medicaid
CA00A565190Medicaid
CA00A565190Medicare ID - Type Unspecified