Provider Demographics
NPI:1245670504
Name:FONG, BRENDAN MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:MANUEL
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 1:12855 N 40 DR STE 375
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-806-1770
Mailing Address - Fax:314-362-2107
Practice Address - Street 1:12855 N 40 DR STE 125
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8663
Practice Address - Country:US
Practice Address - Phone:314-806-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036158187207T00000X
MO2013020671207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery