MEDICARE: DR. DON P 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	06920T	CA
2	152W00000X	Optometrist	270A00377600	NJ
3	152W00000X	Optometrist	OE005239P	PA
4	152WL0500X	Low Vision Rehabilitation Optometrist	06920T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710035068	OTHER	CA	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0790040001	OTHER		PTAN

General Provider Information

NPI Number	:	1710035068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DON P FONG O.D.

Provider Business Mailing Address
First Line	:	3956 J ST
Second Line	:	SUITE 4
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-3625
Country	:	US
Telephone Number	:	916-739-6260
Fax Number	:	916-739-0168

Provider Business Practice Location Address
First Line	:	3956 J ST
Second Line	:	SUITE 4
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-3625
Country	:	US
Telephone Number	:	916-739-6260
Fax Number	:	916-739-0168

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	11/22/2015

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Directions to “ DR. DON P FONG O.D.” Practice Location

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