Provider Demographics
NPI:1043387814
Name:FONG-YIM, ELAINE S (OD)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:S
Last Name:FONG-YIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:S
Other - Last Name:FONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4733 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6021
Mailing Address - Country:US
Mailing Address - Phone:323-783-4011
Mailing Address - Fax:
Practice Address - Street 1:4733 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6021
Practice Address - Country:US
Practice Address - Phone:323-783-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7952TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist