Healthcare Provider Details

I. General information

NPI: 1437166360
Provider Name (Legal Business Name): LQMG MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 E SPRUCE AVE
FRESNO CA
93720
US

IV. Provider business mailing address

1221 E SPRUCE AVE
FRESNO CA
93720
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-5777
  • Fax: 559-449-2654
Mailing address:
  • Phone: 559-450-5777
  • Fax: 559-449-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGER J GONG
Title or Position: PRESIDENT
Credential: MD
Phone: 559-450-5777