Provider Demographics
NPI:1003959693
Name:FONG, SHIRLEY ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:ANN
Last Name:FONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 EL CAMINO REAL
Mailing Address - Street 2:SUITE 404
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1828 EL CAMINO REAL
Practice Address - Street 2:SUITE 404
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3103
Practice Address - Country:US
Practice Address - Phone:650-692-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5265T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist