Provider Demographics
NPI:1477850675
Name:GONG, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-869-6883
Mailing Address - Fax:
Practice Address - Street 1:350 HAWTHORNE AVE
Practice Address - Street 2:RM 2346
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3108
Practice Address - Country:US
Practice Address - Phone:510-869-6883
Practice Address - Fax:510-869-6888
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA133823207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA133823OtherSTATE LICENSE