Provider Demographics
NPI:1689694531
Name:FONG, BRUCE KIRIN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:KIRIN
Last Name:FONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9333 DOUBLE R BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-3102
Mailing Address - Country:US
Mailing Address - Phone:775-828-5388
Mailing Address - Fax:775-828-6588
Practice Address - Street 1:9333 DOUBLE R BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-3102
Practice Address - Country:US
Practice Address - Phone:775-828-5388
Practice Address - Fax:775-828-6588
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2015-10-02
Deactivation Date:2014-11-25
Deactivation Code:
Reactivation Date:2015-02-18
Provider Licenses
StateLicense IDTaxonomies
NV909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine