Provider Demographics
NPI:1912674961
Name:GONG, MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:16709 KEITH DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-2330
Mailing Address - Country:US
Mailing Address - Phone:586-260-4677
Mailing Address - Fax:
Practice Address - Street 1:350 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-1224
Practice Address - Country:US
Practice Address - Phone:518-822-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT009439-01152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist