Provider Demographics
NPI:1427023100
Name:FONG, CARLETON SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLETON
Middle Name:SCOTT
Last Name:FONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 DARLINGTON
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-0222
Mailing Address - Country:US
Mailing Address - Phone:714-679-0516
Mailing Address - Fax:
Practice Address - Street 1:26750 TOWNE CENTRE DRIVE SUITE E
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610
Practice Address - Country:US
Practice Address - Phone:949-215-0505
Practice Address - Fax:949-916-0880
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10689T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP10689TMedicare PIN