Provider Demographics
NPI:1548641426
Name:GONG, YUAN YUAN (MD)
Entity type:Individual
Prefix:MS
First Name:YUAN YUAN
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:GONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:3991 DUTCHMANS LN STE 303
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4723
Practice Address - Country:US
Practice Address - Phone:502-559-1750
Practice Address - Fax:502-666-7707
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12506782207V00000X
KY56099207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology