Provider Demographics
NPI:1790859718
Name:FAN, FONG-LIANG (MD)
Entity Type:Individual
Prefix:DR
First Name:FONG-LIANG
Middle Name:
Last Name:FAN
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 1:550 S BERETANIA ST
Mailing Address - Street 2:STE 403
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2496
Mailing Address - Country:US
Mailing Address - Phone:808-523-0166
Mailing Address - Fax:808-528-4940
Practice Address - Street 1:2226 LILIHA STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-1605
Practice Address - Country:US
Practice Address - Phone:808-523-0166
Practice Address - Fax:808-528-4940
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3280208600000X, 204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000BDSFGOtherMEDICARE
193072OtherHMA NEW
04715601OtherALOHACARE
D36114OtherKAISER PERM
00N0053586OtherHMSA
04715601OtherMEDICAID
HI04715601Medicaid
D3280OtherMDX
D36114Medicare UPIN