Healthcare Provider Details

I. General information

NPI: 1730282716
Provider Name (Legal Business Name): LYNETTE FONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 41ST AVE STE D
CAPITOLA CA
95010-2516
US

IV. Provider business mailing address

1595 SOQUEL DR STE 330
SANTA CRUZ CA
95065-1719
US

V. Phone/Fax

Practice location:
  • Phone: 831-476-3000
  • Fax: 831-476-9009
Mailing address:
  • Phone: 831-465-7761
  • Fax: 831-475-1156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG75170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: