1245520907 NPI number — GLORIA C FONG, M.D., INC

Table of content: (NPI 1245520907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245520907 NPI number — GLORIA C FONG, M.D., INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLORIA C FONG, M.D., INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245520907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 SCHOOLHOUSE RD
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
HOCKESSIN
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19707-9526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-239-6282
Provider Business Mailing Address Fax Number:
302-239-6458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 SCHOOLHOUSE RD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
HOCKESSIN
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19707-9526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-239-6282
Provider Business Practice Location Address Fax Number:
302-239-6458
Provider Enumeration Date:
04/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FONG
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
302-239-6282

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C10002395 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000015701 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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