Provider Demographics
NPI:1245790666
Name:KONG, TRACIE YIQING (MD)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:YIQING
Last Name:KONG
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 1:3650 MIDVALE AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6667
Mailing Address - Country:US
Mailing Address - Phone:732-895-4369
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ STE 1638
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-2105
Practice Address - Country:US
Practice Address - Phone:310-267-8797
Practice Address - Fax:310-267-2059
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program