Provider Demographics
NPI:1154312312
Name:FONG, PETER EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:EDWARD
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:PO BOX 80883
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0883
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:706-549-0151
Practice Address - Street 1:106 ALLEN ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2602
Practice Address - Country:US
Practice Address - Phone:706-549-8114
Practice Address - Fax:706-549-0151
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056467208VP0014X
GA56467207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA644068458TMedicaid
GA644068458VMedicaid
GA644068458XMedicaid
GA644068458YMedicaid
GA644068458WMedicaid
GA644068458UMedicaid
GAE35953Medicare UPIN
GA644068458TMedicaid