Provider Demographics
NPI:1558399584
Name:FONG, ANNA (OD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 N 1ST ST
Mailing Address - Street 2:#102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3900
Mailing Address - Country:US
Mailing Address - Phone:559-438-0600
Mailing Address - Fax:559-438-0698
Practice Address - Street 1:6700 N 1ST ST
Practice Address - Street 2:#102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-3900
Practice Address - Country:US
Practice Address - Phone:559-438-0600
Practice Address - Fax:559-438-0698
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066590Medicaid
CASD0066590Medicare PIN
CASD0066590Medicaid
CA0723660001Medicare NSC