Basic Information
| Provider Information | |||||||||
| NPI: | 1336108018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 CATHARINE ST | ||||||||
| Address2: | P.O. BOX 550 | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1866868841 | ||||||||
| FaxNumber: | 8457902675 | ||||||||
| Practice Location | |||||||||
| Address1: | NY METHODIST HOSPITAL | ||||||||
| Address2: | 506 6TH STREET | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187803279 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 202935-1 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02021570 | 05 | NY | MEDICAID |