Provider Demographics
NPI:1629307665
Name:MINCH K. FONG M.D. INC.
Entity Type:Organization
Organization Name:MINCH K. FONG M.D. INC.
Other - Org Name:MINCH K. FONG M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:EMINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-770-8168
Mailing Address - Street 1:24953 PASEO DE VALENCIA
Mailing Address - Street 2:#25 B
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4342
Mailing Address - Country:US
Mailing Address - Phone:949-770-8168
Mailing Address - Fax:949-770-2991
Practice Address - Street 1:26691 PLAZA
Practice Address - Street 2:STE. 200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6329
Practice Address - Country:US
Practice Address - Phone:949-347-0600
Practice Address - Fax:949-347-0746
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINCH K. FONG M.D. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-22
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78910207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G789100Medicaid
CAG78910Medicare PIN
CAG79043Medicare UPIN