Provider Demographics
NPI:1396861522
Name:FONG, SAMPSON (O D)
Entity Type:Individual
Prefix:
First Name:SAMPSON
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20046 LAKE CHABOT RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5304
Mailing Address - Country:US
Mailing Address - Phone:510-881-8823
Mailing Address - Fax:
Practice Address - Street 1:20046 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5304
Practice Address - Country:US
Practice Address - Phone:510-881-8823
Practice Address - Fax:510-881-2134
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8180T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist