Healthcare Provider Details

I. General information

NPI: 1689844318
Provider Name (Legal Business Name): KENT KEITH FUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W BONITA AVE SUITE 200
POMONA CA
91767-1863
US

IV. Provider business mailing address

250 W BONITA AVE SUITE 200
POMONA CA
91767-1863
US

V. Phone/Fax

Practice location:
  • Phone: 909-629-5067
  • Fax: 909-865-7688
Mailing address:
  • Phone: 909-629-5067
  • Fax: 909-865-7688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA98253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: