Provider Demographics
NPI:1871223271
Name:FONG, PRESTON L
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:L
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22201 MOROSS RD STE 155
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2152
Mailing Address - Country:US
Mailing Address - Phone:313-499-4775
Mailing Address - Fax:313-499-4953
Practice Address - Street 1:22201 MOROSS RD STE 155
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2152
Practice Address - Country:US
Practice Address - Phone:313-499-4775
Practice Address - Fax:313-499-4953
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program