Provider Demographics
NPI:1568469161
Name:FONG, PAMELA J (OD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:J
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 1:1881 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3220
Mailing Address - Country:US
Mailing Address - Phone:650-692-1792
Mailing Address - Fax:650-692-4245
Practice Address - Street 1:1881 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3220
Practice Address - Country:US
Practice Address - Phone:650-692-1792
Practice Address - Fax:650-692-4245
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7461T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074610Medicare ID - Type UnspecifiedMEDICARE NUMBER
CAT10538Medicare UPIN