=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336383637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PING GU MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2009
-----------------------------------------------------
Last Update Date | 10/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 SUMMIT AVENUE
-----------------------------------------------------
City | MONTVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-775-7183
-----------------------------------------------------
Fax | 201-691-6661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 SUMMIT AVENUE
-----------------------------------------------------
City | MONTVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-775-7183
-----------------------------------------------------
Fax | 201-691-6661
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number | 250997
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------