Provider Demographics
NPI:1578129664
Name:CHONG, GAO
Entity Type:Individual
Prefix:
First Name:GAO
Middle Name:
Last Name:CHONG
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 1:3663 SOLANO AVE APT 161
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2773
Mailing Address - Country:US
Mailing Address - Phone:310-954-7697
Mailing Address - Fax:
Practice Address - Street 1:2425 JOHNS WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8367
Practice Address - Country:US
Practice Address - Phone:310-954-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist