Healthcare Provider Details

I. General information

NPI: 1215047659
Provider Name (Legal Business Name): LEO L. FONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 WILLOW AVE STE 101
CLOVIS CA
93612-4714
US

IV. Provider business mailing address

3120 WILLOW AVE STE 101
CLOVIS CA
93612-4714
US

V. Phone/Fax

Practice location:
  • Phone: 559-721-4910
  • Fax: 559-721-4920
Mailing address:
  • Phone: 209-613-2927
  • Fax: 209-538-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG79576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: