Healthcare Provider Details

I. General information

NPI: 1568469161
Provider Name (Legal Business Name): PAMELA J. FONG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 EL CAMINO REAL
BURLINGAME CA
94010-3220
US

IV. Provider business mailing address

1881 EL CAMINO REAL
BURLINGAME CA
94010-3220
US

V. Phone/Fax

Practice location:
  • Phone: 650-692-1792
  • Fax: 650-692-4245
Mailing address:
  • Phone: 650-692-1792
  • Fax: 650-692-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7461T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: