Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | G81504 | CA |
NPI | 1033297163 |
---|---|
Provider Name | Bryan Philip Fong |
First Address | Oakland, CA 94612-3466 |
Second Address | Walnut Creek, CA 94596-5318 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 06/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G815040 | (05) | CA |
G68151 | (02) |