Provider Demographics
NPI:1841261054
Name:FONG, JOHN (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
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:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-0986
Mailing Address - Country:US
Mailing Address - Phone:209-339-9036
Mailing Address - Fax:209-339-1901
Practice Address - Street 1:1130 MONACO CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207
Practice Address - Country:US
Practice Address - Phone:209-478-2060
Practice Address - Fax:209-478-3175
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG494942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G494940Medicaid
CA00G494940Medicare ID - Type Unspecified
CA00G494940Medicaid