Provider Demographics
NPI:1467422550
Name:FANG, KATHY (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EVELYN AVE STE 118
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1350
Mailing Address - Country:US
Mailing Address - Phone:510-207-9875
Mailing Address - Fax:
Practice Address - Street 1:#118 PLAZA PROFESSIONAL BUILDING
Practice Address - Street 2:EL CERRITO PLAZA
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530
Practice Address - Country:US
Practice Address - Phone:510-524-0224
Practice Address - Fax:510-524-0215
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH17510Medicare UPIN
CAZZZ31232ZMedicare PIN
CA00A551102Medicare ID - Type Unspecified