=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629321849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAREN ANN FONG MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2012
-----------------------------------------------------
Last Update Date | 03/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 BISHOP ST SUITE 310
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-4635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-242-4455
-----------------------------------------------------
Fax | 805-547-1395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1241 JOHNSON AVE #322
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-242-4455
-----------------------------------------------------
Fax | 805-547-1395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. KAREN ANN FONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-242-4455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G70251
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G70251
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------