Healthcare Provider Details

I. General information

NPI: 1548846140
Provider Name (Legal Business Name): CLARENCE KONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 MONTAUK HWY
WEST ISLIP NY
11795-4403
US

IV. Provider business mailing address

380 MONTAUK HWY
WEST ISLIP NY
11795-4403
US

V. Phone/Fax

Practice location:
  • Phone: 631-422-5371
  • Fax:
Mailing address:
  • Phone: 631-422-5371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number334926
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number334926
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: