Provider Demographics
NPI:1033532254
Name:FONDA, EMILY (MD MMM)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:
Last Name:FONDA
Suffix:
Gender:F
Credentials:MD MMM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 VIA KORON
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4913
Mailing Address - Country:US
Mailing Address - Phone:949-939-2885
Mailing Address - Fax:
Practice Address - Street 1:505 CITY PKWY W
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2924
Practice Address - Country:US
Practice Address - Phone:949-939-2885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42852174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist