Provider Demographics
NPI:1245520907
Name:GLORIA C FONG, M.D., INC
Entity type:Organization
Organization Name:GLORIA C FONG, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-239-6282
Mailing Address - Street 1:530 SCHOOLHOUSE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-9526
Mailing Address - Country:US
Mailing Address - Phone:302-239-6282
Mailing Address - Fax:302-239-6458
Practice Address - Street 1:530 SCHOOLHOUSE RD
Practice Address - Street 2:SUITE G
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-9526
Practice Address - Country:US
Practice Address - Phone:302-239-6282
Practice Address - Fax:302-239-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000015701Medicaid
DE046954Medicare PIN