Provider Demographics
NPI:1629140819
Name:SOOHOO, LILLIAN FONG (MD)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:FONG
Last Name:SOOHOO
Suffix:
Gender:F
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:PO BOX 1497
Mailing Address - Street 2:L
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95031-1497
Mailing Address - Country:US
Mailing Address - Phone:408-836-9030
Mailing Address - Fax:408-395-8648
Practice Address - Street 1:2490 HOSPITAL DRIVE
Practice Address - Street 2:THE MENKES CLINIC SUITE 201
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4124
Practice Address - Country:US
Practice Address - Phone:650-962-4600
Practice Address - Fax:650-962-4602
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49205OtherMEDICAL LICENSE