Provider Demographics
NPI:1134786338
Name:FONG, JONATHAN MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:FONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2309
Mailing Address - Country:US
Mailing Address - Phone:415-664-3600
Mailing Address - Fax:
Practice Address - Street 1:1372 9TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2309
Practice Address - Country:US
Practice Address - Phone:415-664-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist