Provider Demographics
NPI:1629140918
Name:FONG, WALTER (DC)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 SLATER AVENUE
Mailing Address - Street 2:STE #113
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4742
Mailing Address - Country:US
Mailing Address - Phone:714-965-1957
Mailing Address - Fax:714-593-5828
Practice Address - Street 1:10101 SLATER AVENUE
Practice Address - Street 2:STE #113
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4742
Practice Address - Country:US
Practice Address - Phone:714-965-1957
Practice Address - Fax:714-593-5828
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12402111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WDC12402AMedicare UPIN