Provider Demographics
NPI:1053497149
Name:GONG, CHRISTOPHER BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:BRIAN
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 1:1040 S VAN DYKE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9646
Mailing Address - Country:US
Mailing Address - Phone:989-269-6911
Mailing Address - Fax:989-269-9162
Practice Address - Street 1:1040 S VAN DYKE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9646
Practice Address - Country:US
Practice Address - Phone:989-269-6911
Practice Address - Fax:989-269-9162
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105202208600000X
MI43010617599208600000X
WI39798-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01601930371OtherAMA
MIBG4514510OtherDEA
MIBG4514510OtherDEA
MIG19733Medicare UPIN