Provider Demographics
NPI:1821627514
Name:FONG, PETER (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:25 MICHIGAN ST NE STE 2100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2526
Mailing Address - Country:US
Mailing Address - Phone:616-391-3777
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 2100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2526
Practice Address - Country:US
Practice Address - Phone:616-391-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101027816208D00000X
390200000X
MI5151014391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program