Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | ME50150 | FL |
NPI | 1003804568 |
---|---|
Provider Name | Billy Sana Kong |
First Address | Bartow, FL 33830-6738 |
Second Address | Bartow, FL 33830-6735 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2005 |
Last Update Date | 11/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
061584600 | (05) | FL |
E65231 | (02) |