Provider Demographics
NPI:1265540462
Name:GONG, MERRY BETH (MD)
Entity type:Individual
Prefix:
First Name:MERRY
Middle Name:BETH
Last Name:GONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-2739
Mailing Address - Country:US
Mailing Address - Phone:510-601-6060
Mailing Address - Fax:510-428-4594
Practice Address - Street 1:2344 6TH ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2412
Practice Address - Country:US
Practice Address - Phone:510-981-3203
Practice Address - Fax:510-553-2169
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32302208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ89670ZOtherPTAN
CA00G323020Medicaid
A45095Medicare UPIN
CAZZZ89670ZOtherPTAN