Provider Demographics
NPI:1508851908
Name:KONG, STEPHANIE H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:H
Last Name:KONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 HANNAHS MILL RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-2801
Mailing Address - Country:US
Mailing Address - Phone:706-938-0990
Mailing Address - Fax:
Practice Address - Street 1:210 HANNAHS MILL RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-2801
Practice Address - Country:US
Practice Address - Phone:706-938-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA956718471FMedicaid
GA956718471BMedicaid
GAE68974Medicare UPIN
GA956718471BMedicaid