Healthcare Provider Details

I. General information

NPI: 1437094687
Provider Name (Legal Business Name): FONG WANG RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GLORIA WANG RD

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 BLUE OAK LN W
MADERA CA
93636-8952
US

IV. Provider business mailing address

516 BLUE OAK LN W
MADERA CA
93636-8952
US

V. Phone/Fax

Practice location:
  • Phone: 510-857-6929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: