Provider Demographics
NPI:1417391582
Name:FONG, SUSAN LEE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:FONG
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:SOJUNG
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4200
Mailing Address - Fax:
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.1360972084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program