Provider Demographics
NPI:1760845952
Name:BAO, CHENGMO
Entity Type:Individual
Prefix:
First Name:CHENGMO
Middle Name:
Last Name:BAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1725
Mailing Address - Country:US
Mailing Address - Phone:347-721-0271
Mailing Address - Fax:516-676-6833
Practice Address - Street 1:12 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1725
Practice Address - Country:US
Practice Address - Phone:347-721-0271
Practice Address - Fax:516-676-6833
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist