Healthcare Provider Details

I. General information

NPI: 1518346303
Provider Name (Legal Business Name): DUSTIN KONG CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 KNOLLWOOD RD. SUITE 108
WHITE PLAINS NY
10603-1916
US

IV. Provider business mailing address

399 KNOLLWOOD ROAD SUITE 108
WHITE PLAINS NY
10603-1916
US

V. Phone/Fax

Practice location:
  • Phone: 914-949-8501
  • Fax: 914-949-8502
Mailing address:
  • Phone: 914-949-8501
  • Fax: 914-949-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License NumberCNIM#2717
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: