Provider Demographics
NPI:1083084594
Name:FONG, DANIEL JORDAN (DPT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JORDAN
Last Name:FONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 MERIDIAN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5352
Mailing Address - Country:US
Mailing Address - Phone:408-979-2300
Mailing Address - Fax:408-979-2306
Practice Address - Street 1:1530 MERIDIAN AVE STE 150
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5352
Practice Address - Country:US
Practice Address - Phone:408-979-2300
Practice Address - Fax:408-979-2306
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43033OtherPHYSICAL THERAPY LICENSE