1427210889 NPI number — DR. VIVIEN S FONGUE FONGUE D.O

Table of content: DR. VIVIEN S FONGUE FONGUE D.O (NPI 1427210889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427210889 NPI number — DR. VIVIEN S FONGUE FONGUE D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONGUE FONGUE
Provider First Name:
VIVIEN
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
M

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:
1427210889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100905
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-0905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-662-0600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 SW 72ND ST
Provider Second Line Business Practice Location Address:
SUITE 602
Provider Business Practice Location Address City Name:
SOUTH MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33143-4828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-662-0600
Provider Business Practice Location Address Fax Number:
786-533-9419
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  272692 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03850373 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105800100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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