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General NPI Number Information
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NPI Number | 1912674961
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Entity Type | Individual
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Provider Name | MICHELLE GONG OD
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Gender | Female
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Dates
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Enumeration Date | 08/26/2021
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Last Update Date | 08/26/2021
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Provider Practice Location Address
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Address Line | 350 FAIRVIEW AVE
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City | HUDSON
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State | NY
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Zip | 12534-1224
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Country | US
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Telephone | 518-822-8550
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Fax |
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Provider Business Mailing Address
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Address Line | 16709 KEITH DR
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City | MACOMB
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State | MI
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Zip | 48042-2330
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Country | US
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Telephone | 586-260-4677
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | T009439-01
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License Number State | NY
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