Provider Demographics
NPI:1366823221
Name:FONG, VERISSA LAM (OD)
Entity Type:Individual
Prefix:DR
First Name:VERISSA
Middle Name:LAM
Last Name:FONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BATTERY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-4903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:#72
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4201
Practice Address - Country:US
Practice Address - Phone:415-321-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15279152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist