Provider Demographics
NPI:1568688927
Name:DR THOMAS Y FONG OD INC
Entity Type:Organization
Organization Name:DR THOMAS Y FONG OD INC
Other - Org Name:EYEWEAR DESIGNS OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-888-0303
Mailing Address - Street 1:1241 GRASS VALLEY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-3413
Mailing Address - Country:US
Mailing Address - Phone:530-888-0303
Mailing Address - Fax:530-888-0855
Practice Address - Street 1:1241 GRASS VALLEY HIGHWAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-3413
Practice Address - Country:US
Practice Address - Phone:530-888-0303
Practice Address - Fax:530-888-0855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0071870Medicaid
CASD0071870Medicaid
T10488Medicare UPIN