Provider Demographics
NPI:1811550338
Name:FAN, RONG (MD)
Entity Type:Individual
Prefix:
First Name:RONG
Middle Name:
Last Name:FAN
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 1:625 S FAIR OAKS AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2666
Mailing Address - Country:US
Mailing Address - Phone:626-304-2626
Mailing Address - Fax:
Practice Address - Street 1:625 S FAIR OAKS AVE STE 255
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2666
Practice Address - Country:US
Practice Address - Phone:626-304-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2023-07-03
Deactivation Date:2019-12-04
Deactivation Code:
Reactivation Date:2020-01-07
Provider Licenses
StateLicense IDTaxonomies
CAA185813207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program