Provider Demographics
NPI:1770574816
Name:FENG, FANG (MD PHD)
Entity type:Individual
Prefix:DR
First Name:FANG
Middle Name:
Last Name:FENG
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 LAWRENCEVILLE HWY
Mailing Address - Street 2:STE 106
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033
Mailing Address - Country:US
Mailing Address - Phone:770-938-6989
Mailing Address - Fax:770-938-6948
Practice Address - Street 1:2785 LAWRENCEVILLE HWY
Practice Address - Street 2:STE 106
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:770-938-6989
Practice Address - Fax:770-938-6948
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050798207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000942972AMedicaid
GA000942972AMedicaid
GA11BDVJJMedicare ID - Type Unspecified