Provider Demographics
NPI:1679936066
Name:KONG, DEREK KAI (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:KAI
Last Name:KONG
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 1:15 CORPORATE DR STE 2-8
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-1351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 CORPORATE DR STE 2-8
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1351
Practice Address - Country:US
Practice Address - Phone:203-452-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT71215207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program