Basic Information
| Provider Information | |||||||||
| NPI: | 1952559585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 550 W RANCH VIEW DR | ||||||||
| Address2: | STE. 3000 | ||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957655391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164091400 | ||||||||
| FaxNumber: | 9164091499 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 W RANCH VIEW DR | ||||||||
| Address2: | STE. 3000 | ||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957655391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164091400 | ||||||||
| FaxNumber: | 9164091499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A9698 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20A9698 | 01 | CA | STATE MEDICAL LICENSE | OTHER |