Provider Demographics
NPI:1114034113
Name:GONG, ALICE KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:KIM
Last Name:GONG
Suffix:
Gender:F
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:UTHSCSA, UTHSCSA, DEPT. OF PEDIATRICS
Mailing Address - Street 2:7703 FLOYD CURL DRIVE, MSC 7812
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3900
Mailing Address - Country:US
Mailing Address - Phone:210-358-1593
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR FL 5
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-257-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG91042080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103027201Medicaid