Provider Demographics
NPI:1851302459
Name:FONG, GLORIA C (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:C
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 1:530 SCHOOLHOUSE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-9526
Mailing Address - Country:US
Mailing Address - Phone:302-239-6282
Mailing Address - Fax:302-239-6458
Practice Address - Street 1:530 SCHOOLHOUSE RD
Practice Address - Street 2:SUITE G
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-9526
Practice Address - Country:US
Practice Address - Phone:302-239-6282
Practice Address - Fax:302-239-6458
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0074160000OtherAMERIHEALTH
DE4271807OtherAETNA
DE32288OtherCOVENTRY
DE0000015701Medicaid
DE046954Medicare ID - Type Unspecified
DE32288OtherCOVENTRY