Provider Demographics
NPI:1407284177
Name:GONG, BENCHUAN (MD (CHINA))
Entity Type:Individual
Prefix:DR
First Name:BENCHUAN
Middle Name:
Last Name:GONG
Suffix:
Gender:M
Credentials:MD (CHINA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 N KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5110
Mailing Address - Country:US
Mailing Address - Phone:773-583-2142
Mailing Address - Fax:
Practice Address - Street 1:4921 N KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5110
Practice Address - Country:US
Practice Address - Phone:773-583-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001152171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist