Provider Demographics
NPI:1508558115
Name:GONG, WENWEN
Entity Type:Individual
Prefix:
First Name:WENWEN
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 1:3145 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3145 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1521
Practice Address - Country:US
Practice Address - Phone:845-823-4063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist