Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | G80754 | CA |
Y | 207ND0900X | Dermatopathologist | G80754 | CA |
NPI | 1134178973 |
---|---|
Provider Name | Dr. Maxwell Fung |
First Address | Sacramento, CA 95816-3300 |
Second Address | Sacramento, CA 95816-3300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2006 |
Last Update Date | 07/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G807541 | (02) | CA |