Individual
DEREK PATRICK GONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
16319 THIRD STREET, SANTA ROSA, CA 95409
(707) 869-2849
(707) 869-1477
Mailing address
16319 THIRD STREET, SANTA ROSA, CA 95446
(707) 869-2849
(707) 869-1477
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
A66344
CA
208000000X
Pediatrics Physician
A66344
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00A663440
—
CA
05
—
FHC03887F
—
CA
01
—
ZZZ73222Z
GROUP PTAN
CA
Enumeration date
05/30/2006
Last updated
11/28/2007
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