Healthcare Provider Details

I. General information

NPI: 1669648408
Provider Name (Legal Business Name): RONG FAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 W WASHINGTON AVE STE 301
LAS VEGAS NV
89128-4340
US

IV. Provider business mailing address

1355 RIVER BEND DR
DALLAS TX
75247-4915
US

V. Phone/Fax

Practice location:
  • Phone: 702-732-3441
  • Fax:
Mailing address:
  • Phone: 27-732-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01065131A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301510501
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number313196-01
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number27457
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: