Provider Demographics
NPI:1043347859
Name:FONG, TINA HUEY (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:HUEY
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 1:12417 FAIR OAKS BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2501
Mailing Address - Country:US
Mailing Address - Phone:916-722-4280
Mailing Address - Fax:916-722-0148
Practice Address - Street 1:12417 FAIR OAKS BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-2501
Practice Address - Country:US
Practice Address - Phone:916-722-4280
Practice Address - Fax:916-722-0148
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA207231OtherCOLE & PEARL VISION ID #
CA211137OtherEYEMED ID #
CAGR0052200Medicaid
CA13565OtherMEDICAL EYE SERVICES ID #
CA207231OtherCOLE & PEARL VISION ID #
CA0379230001Medicare NSC
CA211137OtherEYEMED ID #
CAGR0052200Medicaid