Provider Demographics
NPI:1851324370
Name:FONG, NANCY WANG (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:WANG
Last Name:FONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:1ST FL,MSC9152
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6299
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7494
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-069513207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH743236OtherBUCKEYE
OHP00454334OtherRAILROAD MEDICARE
OH1851324370OtherMI MEDICAID
OH220029791OtherRAILROAD MEDICARE
OH000000224339OtherUNISON
OH000000528781OtherANTHEM
OH364110OtherWELLCARE
OH000000188079OtherANTHEM
OH2068157OtherUHC
OH0127464OtherBCMH
OH2213250Medicaid
OH7849101OtherAETNA
OHWA4026122Medicare PIN
OH1851324370OtherMI MEDICAID
OHH12976Medicare UPIN