Provider Demographics
NPI:1184734121
Name:FONG, DANIEL K (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:K
Last Name:FONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FREEPORT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-2701
Mailing Address - Country:US
Mailing Address - Phone:916-451-4494
Mailing Address - Fax:916-451-4229
Practice Address - Street 1:5301 FREEPORT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-2701
Practice Address - Country:US
Practice Address - Phone:916-451-4494
Practice Address - Fax:916-451-4229
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8718T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0087180Medicaid
CAU22085Medicare UPIN
CASD0087180Medicare ID - Type Unspecified