Healthcare Provider Details

I. General information

NPI: 1306866033
Provider Name (Legal Business Name): SHIRLEY FONG TING M. B.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FONG TING M.B.

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10050 IMPERIAL AVE
CUPERTINO CA
95014-5905
US

IV. Provider business mailing address

1565 VINEYARD DR
LOS ALTOS CA
94024-7261
US

V. Phone/Fax

Practice location:
  • Phone: 408-865-0936
  • Fax: 408-865-0976
Mailing address:
  • Phone: 650-691-9608
  • Fax: 650-691-9608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA43758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: