Provider Demographics
NPI:1851396816
Name:FONG, KAREN ANN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
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 1:184 CASA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1804
Mailing Address - Country:US
Mailing Address - Phone:805-242-4455
Mailing Address - Fax:805-542-9589
Practice Address - Street 1:184 CASA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1804
Practice Address - Country:US
Practice Address - Phone:805-242-4455
Practice Address - Fax:805-542-9589
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70251207R00000X
CAG070251208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG70251OtherB;UE CROSS
CA00G702510OtherBLUE SHIELD
P00126190Medicare PIN
CAG70251OtherB;UE CROSS
WG70251IMedicare PIN