Provider Demographics
NPI:1346279189
Name:GONG, RICHARD JOHN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:GONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:J
Other - Last Name:GONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:2455 NE LOOP 410
Mailing Address - Street 2:STE 245
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217
Mailing Address - Country:US
Mailing Address - Phone:210-654-0866
Mailing Address - Fax:210-654-8723
Practice Address - Street 1:2455 NE LOOP 410
Practice Address - Street 2:STE 245
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-654-0866
Practice Address - Fax:210-654-8723
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9105208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032677901OtherTPI
TXP000D68F8Medicaid
TX032677901OtherTPI
C16228Medicare UPIN