MEDICARE: MR. LUIS GUSTAVO FONG MSED

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	174400000X	Specialist		NY

General Provider Information

NPI Number	:	1508155862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LUIS GUSTAVO FONG MSED

Provider Business Mailing Address
First Line	:	9834 ALSTYNE AVE
Second Line	:	FLOOR 2
City	:	CORONA
State	:	NY
Zip	:	11368-2720
Country	:	US
Telephone Number	:	917-279-7644
Fax Number	:

Provider Business Practice Location Address
First Line	:	9834 ALSTYNE AVE
Second Line	:	FLOOR 2
City	:	CORONA
State	:	NY
Zip	:	11368-2720
Country	:	US
Telephone Number	:	917-279-7644
Fax Number	:

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

Provider Enumeration Date	:	04/07/2011
Last Update Date	:	07/21/2022

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