Provider Demographics
NPI:1902520166
Name:DOCTOR GONG INTERNAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:DOCTOR GONG INTERNAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BING
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-658-3148
Mailing Address - Street 1:68 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DEMAREST
Mailing Address - State:NJ
Mailing Address - Zip Code:07627-2715
Mailing Address - Country:US
Mailing Address - Phone:201-658-3148
Mailing Address - Fax:
Practice Address - Street 1:68 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:DEMAREST
Practice Address - State:NJ
Practice Address - Zip Code:07627-2715
Practice Address - Country:US
Practice Address - Phone:212-305-2862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty