Provider Demographics
NPI:1508197682
Name:KONG, MABEL AYE AYE MYAING
Entity Type:Individual
Prefix:
First Name:MABEL
Middle Name:AYE AYE MYAING
Last Name:KONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AYE
Other - Middle Name:AYE
Other - Last Name:MYAING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8337 SAINT JAMES AVE
Mailing Address - Street 2:APT 4U
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3707
Mailing Address - Country:US
Mailing Address - Phone:646-510-6066
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:646-510-6066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine