Basic Information
| Provider Information | |||||||||
| NPI: | 1932388444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | KENTON | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1238 12TH AVE APT 4 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941222235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507996298 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 845 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941334899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159822400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | A93721 | CA | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | A93721 | 01 | CA | MEDICAL LICENSE | OTHER |