Provider Demographics
NPI: | 1851364806 |
---|---|
Name: | GONJON, CHENG A (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | CHENG |
Middle Name: | A |
Last Name: | GONJON |
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: | 9 SICKLES ST |
Mailing Address - Street 2: | SUITE 1A |
Mailing Address - City: | NEW YORK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10040-1642 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 212-304-0096 |
Mailing Address - Fax: | 212-304-0037 |
Practice Address - Street 1: | 9 SICKLES ST |
Practice Address - Street 2: | SUITE 1A |
Practice Address - City: | NEW YORK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10040-1642 |
Practice Address - Country: | US |
Practice Address - Phone: | 212-304-0096 |
Practice Address - Fax: | 212-304-0037 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-02-09 |
Last Update Date: | 2011-02-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 201244 | 207P00000X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 1663872 | Medicaid | |
NY | 587091 | Medicare ID - Type Unspecified | |
NY | G31177 | Medicare UPIN | |
NY | 1663872 | Medicaid |