Provider Demographics
NPI:1861661787
Name:ARNOLD D FONG MD PA
Entity Type:Organization
Organization Name:ARNOLD D FONG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-280-8228
Mailing Address - Street 1:1102 A1A N
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4098
Mailing Address - Country:US
Mailing Address - Phone:904-280-8228
Mailing Address - Fax:
Practice Address - Street 1:1102 A1A N
Practice Address - Street 2:SUITE 106
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-4098
Practice Address - Country:US
Practice Address - Phone:904-280-8228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23972AMedicare PIN
FLF77211Medicare UPIN