Provider Demographics
NPI:1710048483
Name:FUNG, JASON FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:FREDERICK
Last Name:FUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 WEBSTER ST
Mailing Address - Street 2:#509
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-452-0330
Mailing Address - Fax:510-452-2152
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:#509
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-452-0330
Practice Address - Fax:510-452-2152
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA086935207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H81981Medicare UPIN
CA00A869350Medicare ID - Type Unspecified