Healthcare Provider Details

I. General information

NPI: 1558215533
Provider Name (Legal Business Name): CODY GONG LEONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2508
US

IV. Provider business mailing address

2229 BLAKE ST APT 510
DENVER CO
80205-3063
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7000
  • Fax:
Mailing address:
  • Phone: 720-880-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: