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NPI Code Detail

MEDICARE: MATTHEW BRYAN FONG M.D.

MEDICARE: MATTHEW BRYAN FONG M.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
1208000000XPediatrics PhysicianA113013CA

General Provider Information

NPI Number : 1346412244
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW BRYAN FONG M.D.
Provider Business Mailing Address
First Line : COLEMAN PAVILION, ROOM A1121
Second Line : 11175 CAMPUS STREET
City : LOMA LINDA
State : CA
Zip : 92350
Country : US
Telephone Number : 909-558-8142
Fax Number :
Provider Business Practice Location Address
First Line : 250 S G ST
Second Line :
City : SAN BERNARDINO
State : CA
Zip : 92410-3320
Country : US
Telephone Number : 909-382-7100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/31/2008
Last Update Date : 07/21/2022

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