Provider Demographics
NPI:1104019116
Name:PAMELA J. FONG, O.D.
Entity Type:Organization
Organization Name:PAMELA J. FONG, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:650-692-1792
Mailing Address - Street 1:1881 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3220
Mailing Address - Country:US
Mailing Address - Phone:650-692-1792
Mailing Address - Fax:650-692-4245
Practice Address - Street 1:1881 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3220
Practice Address - Country:US
Practice Address - Phone:650-692-1792
Practice Address - Fax:650-692-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7461T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0229610001Medicare NSC
CAZZZ03242ZMedicare PIN