MEDICARE: DR. TINA HUEY FONG O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	7493	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	207231	OTHER	CA	COLE & PEARL VISION ID #
2	211137	OTHER	CA	EYEMED ID #
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	13565	OTHER	CA	MEDICAL EYE SERVICES ID #

General Provider Information

NPI Number	:	1043347859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TINA HUEY FONG O.D.

Provider Business Mailing Address
First Line	:	12417 FAIR OAKS BLVD
Second Line	:	SUITE 500
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-2501
Country	:	US
Telephone Number	:	916-722-4280
Fax Number	:	916-722-0148

Provider Business Practice Location Address
First Line	:	12417 FAIR OAKS BLVD
Second Line	:	SUITE 500
City	:	FAIR OAKS
State	:	CA
Zip	:	95628-2501
Country	:	US
Telephone Number	:	916-722-4280
Fax Number	:	916-722-0148

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/09/2007

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