Provider Demographics
NPI:1851424550
Name:GONG, MARSHAL F (DC)
Entity Type:Individual
Prefix:DR
First Name:MARSHAL
Middle Name:F
Last Name:GONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3248 E SHIELDS AVE STE E
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6915
Mailing Address - Country:US
Mailing Address - Phone:559-226-1695
Mailing Address - Fax:
Practice Address - Street 1:3248 E SHIELDS AVE STE E
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6915
Practice Address - Country:US
Practice Address - Phone:559-226-1695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20981111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0209810Medicaid
CADC0209810Medicare ID - Type Unspecified
CADC0209810Medicaid