Provider Demographics
NPI:1679933105
Name:FONG, KEVIN (DPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 FUNSTON PL
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2522
Mailing Address - Country:US
Mailing Address - Phone:925-683-1505
Mailing Address - Fax:
Practice Address - Street 1:290 DIVISION ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-4892
Practice Address - Country:US
Practice Address - Phone:415-508-5658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist