=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710035068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DON P FONG O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 11/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3956 J ST SUITE 4
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-739-6260
-----------------------------------------------------
Fax | 916-739-0168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3956 J ST SUITE 4
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-739-6260
-----------------------------------------------------
Fax | 916-739-0168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 06920T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 270A00377600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OE005239P
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | 06920T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------