Provider Demographics
NPI:1134203045
Name:GONG, JERALD Z (MD)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:Z
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 1:132 S 10TH ST
Mailing Address - Street 2:285K
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:285K
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:215-503-5642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99-00847207ZP0102X
PAMD438783207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0223620Medicaid
PA001791400-0004Medicaid
NJ0223620Medicaid
PA175969Medicare UPIN
G96040Medicare ID - Type Unspecified
NC2275626Medicare ID - Type Unspecified