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
StateLicense IDTaxonomies
NY201244207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1663872Medicaid
NY587091Medicare ID - Type Unspecified
NYG31177Medicare UPIN
NY1663872Medicaid