Provider Demographics
NPI:1447251970
Name:GONG, BONNIE (MD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 TOTEM LAKE BLVD NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2954
Mailing Address - Country:US
Mailing Address - Phone:425-899-4455
Mailing Address - Fax:425-899-4434
Practice Address - Street 1:12910 TOTEM LAKE BLVD NE
Practice Address - Street 2:SUITE 102
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2954
Practice Address - Country:US
Practice Address - Phone:425-899-4455
Practice Address - Fax:425-899-4434
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037065207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106830Medicaid
WA1106830Medicaid
WA1106830Medicaid
WAE55162Medicare UPIN