Provider Demographics
NPI:1548642655
Name:FONG, DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10418 VALLEY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3600
Mailing Address - Country:US
Mailing Address - Phone:626-453-8466
Mailing Address - Fax:626-453-8465
Practice Address - Street 1:10418 VALLEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-3600
Practice Address - Country:US
Practice Address - Phone:626-453-8466
Practice Address - Fax:626-453-8465
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61094020207Q00000X
MI5101021839207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty