Healthcare Provider Details

I. General information

NPI: 1124224431
Provider Name (Legal Business Name): DANIEL NELSON FONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2007
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 N PORTLAND AVE
OKLAHOMA CITY OK
73120-5045
US

IV. Provider business mailing address

11200 N PORTLAND AVE
OKLAHOMA CITY OK
73120-5045
US

V. Phone/Fax

Practice location:
  • Phone: 405-936-1092
  • Fax: 405-302-5232
Mailing address:
  • Phone: 405-936-1500
  • Fax: 405-302-5232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25623
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: