Provider Demographics
NPI:1013066992
Name:FREDERICK FONG MD INC
Entity Type:Organization
Organization Name:FREDERICK FONG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-531-7551
Mailing Address - Street 1:1380 LUSTIANA STREET
Mailing Address - Street 2:SUITE 514
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2441
Mailing Address - Country:US
Mailing Address - Phone:808-531-7551
Mailing Address - Fax:808-537-3652
Practice Address - Street 1:1380 LUSTIANA STREET
Practice Address - Street 2:SUITE 514
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2441
Practice Address - Country:US
Practice Address - Phone:808-531-7551
Practice Address - Fax:808-537-3652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2477207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI38893OtherBLUE CROSS
HI52862201Medicaid
C98758Medicare UPIN
HI38893OtherBLUE CROSS