Provider Demographics
NPI:1184671513
Name:GONG, DEREK PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:PATRICK
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 1:16319 THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95446
Mailing Address - Country:US
Mailing Address - Phone:707-869-2849
Mailing Address - Fax:707-869-1477
Practice Address - Street 1:16319 THIRD STREET
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409
Practice Address - Country:US
Practice Address - Phone:707-869-2849
Practice Address - Fax:707-869-1477
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66344207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A663440Medicaid
CAZZZ73222ZOtherGROUP PTAN
CAFHC03887FMedicaid
CA551839Medicare Oscar/Certification
CAFHC03887FMedicaid