Provider Demographics
NPI:1962477109
Name:GONG, JANIS VALORIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JANIS
Middle Name:VALORIE
Last Name:GONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 POLLARD RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1435
Mailing Address - Country:US
Mailing Address - Phone:408-378-1701
Mailing Address - Fax:
Practice Address - Street 1:825 POLLARD RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1435
Practice Address - Country:US
Practice Address - Phone:408-378-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5609T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0056090Medicare PIN
CAT10055Medicare UPIN