Provider Demographics
NPI:1629103247
Name:FONG, DENNIS WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:WILLIAM
Last Name:FONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 SUTTER ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2637
Mailing Address - Country:US
Mailing Address - Phone:510-527-6237
Mailing Address - Fax:
Practice Address - Street 1:230 MINOR HALL
Practice Address - Street 2:UC BERKELEY SCHOOL OF OPTOMETRY
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-0001
Practice Address - Country:US
Practice Address - Phone:510-643-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist