Provider Demographics
NPI:1700813359
Name:FONG, DELLA JANG (MD)
Entity Type:Individual
Prefix:DR
First Name:DELLA
Middle Name:JANG
Last Name:FONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:625 SOUTH FAIR OAKS AVENUE
Mailing Address - Street 2:SUITE 255, SOUTH LOBBY
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:626-304-2626
Mailing Address - Fax:626-585-0695
Practice Address - Street 1:625 SOUTH FAIR OAKS AVENUE
Practice Address - Street 2:SUITE 255, SOUTH LOBBY
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105
Practice Address - Country:US
Practice Address - Phone:626-304-2626
Practice Address - Fax:626-585-0695
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79210207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G337270Medicaid
CAW17819Medicare ID - Type Unspecified
CAG32899Medicare UPIN