Provider Demographics
NPI:1841558103
Name:FONG, YI-JEN (MD)
Entity Type:Individual
Prefix:
First Name:YI-JEN
Middle Name:
Last Name:FONG
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 1:775 FERN RDG
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-9028
Mailing Address - Country:US
Mailing Address - Phone:310-339-8534
Mailing Address - Fax:
Practice Address - Street 1:4370 ALPINE RD
Practice Address - Street 2:SUITE #206
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028
Practice Address - Country:US
Practice Address - Phone:650-376-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine