Healthcare Provider Details

I. General information

NPI: 1699834465
Provider Name (Legal Business Name): ROBERT LAWRENCE GONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 MAIN ST STE 3
CAMBRIA CA
93428-3022
US

IV. Provider business mailing address

PO BOX 1238
CAMBRIA CA
93428-1238
US

V. Phone/Fax

Practice location:
  • Phone: 805-927-8671
  • Fax:
Mailing address:
  • Phone: 805-305-3367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG41145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: