Provider Demographics
NPI:1710904321
Name:GONGWER, CAMERON R (MD)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:R
Last Name:GONGWER
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 1:4440 NORTH PORTAGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-8579
Mailing Address - Country:US
Mailing Address - Phone:574-204-6200
Mailing Address - Fax:574-288-1426
Practice Address - Street 1:4440 NORTH PORTAGE AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-8579
Practice Address - Country:US
Practice Address - Phone:574-204-6200
Practice Address - Fax:574-288-1426
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038547A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100092640Medicaid
IN01038547AOtherLICENSE
IN01038547BOtherCONTROLLED SUBSTANCE REG
IN01038547BOtherCONTROLLED SUBSTANCE REG