1790859718 NPI number — DR. FONG-LIANG FAN MD

Table of content: DR. FONG-LIANG FAN MD (NPI 1790859718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790859718 NPI number — DR. FONG-LIANG FAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAN
Provider First Name:
FONG-LIANG
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1790859718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 S BERETANIA ST
Provider Second Line Business Mailing Address:
STE 403
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96813-2496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-523-0166
Provider Business Mailing Address Fax Number:
808-528-4940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2226 LILIHA STREET
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96817-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-523-0166
Provider Business Practice Location Address Fax Number:
808-528-4940
Provider Enumeration Date:
11/20/2006

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: 208600000X , with the licence number:  3280 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204F00000X , with the licence number: 3280 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000BDSFG . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 193072 . This is a "HMA NEW" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04715601 . This is a "ALOHACARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: D36114 . This is a "KAISER PERM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00N0053586 . This is a "HMSA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04715601 . This is a "MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04715601 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: D3280 . This is a "MDX" identifier . This identifiers is of the category "OTHER".




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