Provider Demographics
NPI:1780771626
Name:GONG, JEFFREY (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:GONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S NEW YORK RD
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9609
Mailing Address - Country:US
Mailing Address - Phone:609-652-2730
Mailing Address - Fax:609-652-7463
Practice Address - Street 1:101 S NEW YORK RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9609
Practice Address - Country:US
Practice Address - Phone:609-652-2730
Practice Address - Fax:609-652-7463
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03676700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0081732001OtherAMERIHEALTH
NJ0668206Medicaid
NJ13611OtherAETNA
NJ125066Medicare ID - Type Unspecified
NJ0668206Medicaid