Provider Demographics
NPI:1942705967
Name:GONG, YIRAN (MD)
Entity Type:Individual
Prefix:
First Name:YIRAN
Middle Name:
Last Name:GONG
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 1:7210 JACKSON BLVD APT F1
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-3226
Mailing Address - Country:US
Mailing Address - Phone:918-549-0611
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE RM 7609
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-8757
Practice Address - Fax:708-216-1259
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.073117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine