MEDICARE: DR. PETER FONG O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	007929	NY

General Provider Information

NPI Number	:	1023352689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER FONG O.D.

Provider Business Mailing Address
First Line	:	1148 DEER PARK AVE
Second Line	:
City	:	NORTH BABYLON
State	:	NY
Zip	:	11703-3102
Country	:	US
Telephone Number	:	631-242-0808
Fax Number	:

Provider Business Practice Location Address
First Line	:	1148 DEER PARK AVE
Second Line	:
City	:	NORTH BABYLON
State	:	NY
Zip	:	11703-3102
Country	:	US
Telephone Number	:	631-242-0808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	12/15/2021

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