Provider Demographics
NPI:1316910227
Name:FONG, HON WA (DPM)
Entity type:Individual
Prefix:
First Name:HON
Middle Name:WA
Last Name:FONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 87949
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-0949
Mailing Address - Country:US
Mailing Address - Phone:734-716-6434
Mailing Address - Fax:
Practice Address - Street 1:2050 N HAGGERTY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3795
Practice Address - Country:US
Practice Address - Phone:734-981-1086
Practice Address - Fax:734-981-2259
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002084213ES0103X
MI5904002084213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480D710100OtherHWL BC GROUP
MI4858213520OtherINDIVIDUAL BC
MI4748127Medicaid
MI0M67640005Medicare ID - Type UnspecifiedHWL MEDICARE
V05474Medicare UPIN