Healthcare Provider Details

I. General information

NPI: 1467453266
Provider Name (Legal Business Name): 75TH STREET MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7408 COASTAL HWY
OCEAN CITY MD
21842-2936
US

IV. Provider business mailing address

7408 COASTAL HWY
OCEAN CITY MD
21842-2936
US

V. Phone/Fax

Practice location:
  • Phone: 410-524-0075
  • Fax: 410-524-0066
Mailing address:
  • Phone: 410-524-0075
  • Fax: 410-524-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0032615
License Number StateMD

VIII. Authorized Official

Name: DR. VICTOR GONG
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 410-524-0075