Provider Demographics
NPI:1366641631
Name:FONG, STEPHANIE PAN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:PAN
Last Name:FONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5834 LOUETTA RD STE F
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-7884
Mailing Address - Country:US
Mailing Address - Phone:832-698-4291
Mailing Address - Fax:832-698-4297
Practice Address - Street 1:5834 LOUETTA RD STE F
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-7884
Practice Address - Country:US
Practice Address - Phone:832-698-4291
Practice Address - Fax:832-698-4297
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6617207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics