Provider Demographics
NPI:1881800621
Name:BONG, JEFFREY SOON (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SOON
Last Name:BONG
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 1:2840 REYNOLDS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1904
Mailing Address - Country:US
Mailing Address - Phone:586-949-4946
Mailing Address - Fax:
Practice Address - Street 1:451 SW BETHANY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1964
Practice Address - Country:US
Practice Address - Phone:630-430-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010166352085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101016635OtherMICHIGAN LICENSE NUMBER