Provider Demographics
NPI:1720547706
Name:FONG, LILLIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LILLIAN
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 FOLLY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2641
Mailing Address - Country:US
Mailing Address - Phone:843-795-3344
Mailing Address - Fax:
Practice Address - Street 1:452 FOLLY RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2641
Practice Address - Country:US
Practice Address - Phone:843-795-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88015208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics