Provider Demographics
NPI:1235172677
Name:FONG, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
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 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:
Practice Address - Street 1:7105 W HOOD PL
Practice Address - Street 2:SUITE A 103
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6714
Practice Address - Country:US
Practice Address - Phone:509-735-5551
Practice Address - Fax:509-735-5552
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032458207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG07705Medicare UPIN