Healthcare Provider Details

I. General information

NPI: 1083084594
Provider Name (Legal Business Name): DANIEL JORDAN FONG DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 MERIDIAN AVE STE 150
SAN JOSE CA
95125-5352
US

IV. Provider business mailing address

1530 MERIDIAN AVE STE 150
SAN JOSE CA
95125-5352
US

V. Phone/Fax

Practice location:
  • Phone: 408-979-2300
  • Fax: 408-979-2306
Mailing address:
  • Phone: 408-979-2300
  • Fax: 408-979-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number43033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: