Basic Information
| Provider Information | |||||||||
| NPI: | 1124224431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | NELSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11200 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731205045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059361500 | ||||||||
| FaxNumber: | 4053025232 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731205045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059361092 | ||||||||
| FaxNumber: | 4053025232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2007 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 25623 | OK | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.