Provider Demographics
NPI:1982690095
Name:FONG, BRIAN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
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 1:1209 BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5081
Mailing Address - Country:US
Mailing Address - Phone:985-847-0621
Mailing Address - Fax:985-641-1166
Practice Address - Street 1:2965 GAUSE BLVD E
Practice Address - Street 2:SUITE A
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4154
Practice Address - Country:US
Practice Address - Phone:985-641-7775
Practice Address - Fax:985-641-1166
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10265R207X00000X
HIMD7157207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194920001OtherDME MEDICARE
200030274OtherRAILROAD MEDICARE
C7760OtherBLUE CROSS
1194920001OtherDME MEDICARE
200030274OtherRAILROAD MEDICARE
LA1194920001Medicare NSC