Provider Demographics
NPI:1093132177
Name:CHONG, PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:CHONG
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 1:7798 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4014
Mailing Address - Country:US
Mailing Address - Phone:909-355-1296
Mailing Address - Fax:888-625-5702
Practice Address - Street 1:7798 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4014
Practice Address - Country:US
Practice Address - Phone:909-355-1296
Practice Address - Fax:888-625-5702
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6617208000000X
CAA148270208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics