Provider Demographics
NPI:1528027471
Name:DONG, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:DONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 30TH STREET
Mailing Address - Street 2:SUITE 407
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-419-0230
Mailing Address - Fax:510-419-0273
Practice Address - Street 1:350 30TH STREET
Practice Address - Street 2:SUITE 407
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-419-0230
Practice Address - Fax:510-419-0273
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG032972207R00000X
CAG32972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G329720Medicaid
CAA45365Medicare UPIN
CA00G329720Medicaid
CA00G329720Medicare ID - Type Unspecified