Provider Demographics
NPI:1477834463
Name:FONG, ALLEN GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:GARY
Last Name:FONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3058
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070
Mailing Address - Country:US
Mailing Address - Phone:408-806-1565
Mailing Address - Fax:408-741-1595
Practice Address - Street 1:2039 FOREST AVE
Practice Address - Street 2:STE # 201
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-806-1565
Practice Address - Fax:408-741-1595
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36904207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AF7272672OtherBNDD
AF7272672OtherBNDD
CAA36400Medicare UPIN