Healthcare Provider Details

I. General information

NPI: 1588923668
Provider Name (Legal Business Name): KATHRYN FONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 RICHLAND MEDICAL PARK DR STE 330
COLUMBIA SC
29203-6862
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-7100
  • Fax:
Mailing address:
  • Phone: 803-296-7329
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number83019
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: