Provider Demographics
NPI:1699834465
Name:GONG, ROBERT LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:GONG
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:PO BOX 1238
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA
Mailing Address - State:CA
Mailing Address - Zip Code:93428-1238
Mailing Address - Country:US
Mailing Address - Phone:805-305-3367
Mailing Address - Fax:
Practice Address - Street 1:2150 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:CAMBRIA
Practice Address - State:CA
Practice Address - Zip Code:93428-3022
Practice Address - Country:US
Practice Address - Phone:805-927-8671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G411450Medicaid
CA00G411450Medicaid
CAA48472Medicare UPIN