Provider Demographics
NPI:1639452279
Name:FONG, STEVE
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4771 E PACIFIC COAST HWY
Mailing Address - Street 2:B
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3242
Mailing Address - Country:US
Mailing Address - Phone:415-490-8361
Mailing Address - Fax:
Practice Address - Street 1:12900 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 214A
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2006
Practice Address - Country:US
Practice Address - Phone:714-636-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00000000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program