Provider Demographics
NPI:1083957997
Name:FONG, TODD C (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:C
Last Name:FONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 E SANTA CLARA ST
Mailing Address - Street 2:INTERNAL MEDICINE
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-1934
Mailing Address - Country:US
Mailing Address - Phone:408-977-4423
Mailing Address - Fax:
Practice Address - Street 1:777 E SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1934
Practice Address - Country:US
Practice Address - Phone:408-977-4423
Practice Address - Fax:408-977-8705
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine