Provider Demographics
NPI:1164572236
Name:DONG, GORDON T (PT)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:T
Last Name:DONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5699 KOPIKO ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1668
Mailing Address - Country:US
Mailing Address - Phone:808-329-7744
Mailing Address - Fax:808-334-1608
Practice Address - Street 1:75-5699 KOPIKO ST
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1668
Practice Address - Country:US
Practice Address - Phone:808-329-7744
Practice Address - Fax:808-334-1608
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-1377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI244903-02Medicaid
HIA002OtherTRICARE
HI217706OtherHMA SUMMERLIN LIFE
HI00A0053908OtherHMSA BC BS
HI00A0053908OtherHMSA 65C PLUS
HI00A053908OtherHMSA QUEST
HI244903-01Medicaid