Healthcare Provider Details

I. General information

NPI: 1992023188
Provider Name (Legal Business Name): TIMOTHY ALLAN GONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 03/31/2022
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 WORTH ST STE 250
DALLAS TX
75246-2073
US

IV. Provider business mailing address

3500 GASTON AVE
DALLAS TX
75246-2017
US

V. Phone/Fax

Practice location:
  • Phone: 214-820-6856
  • Fax:
Mailing address:
  • Phone: 214-820-2362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR1373
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: