=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073583498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FONG JAMES WONG M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2006
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 S.E 18TH STREET SUITE 801
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-351-8877
-----------------------------------------------------
Fax | 352-351-8867
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2310 LAUREL RUN DR
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34471-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-369-1717
-----------------------------------------------------
Fax | 352-351-8867
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | ME76024
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------