Healthcare Provider Details

I. General information

NPI: 1255621876
Provider Name (Legal Business Name): ALAN FONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALAN FONG M.D.

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 S 1ST AVE SUITE 101
ARCADIA CA
91006-3607
US

IV. Provider business mailing address

78 REHNBORG DR
BUENA PARK CA
90621-8432
US

V. Phone/Fax

Practice location:
  • Phone: 626-447-7008
  • Fax:
Mailing address:
  • Phone: 562-533-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME123616
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: