Healthcare Provider Details

I. General information

NPI: 1831696160
Provider Name (Legal Business Name): STEPHANIE YING FONG GOMEZ MD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE YING FONG MD, MS

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 01/11/2022
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3331
  • Fax:
Mailing address:
  • Phone: 510-428-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA163399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: