Provider Demographics
NPI:1386177574
Name:FONG, JOSEPH WESLEY (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WESLEY
Last Name:FONG
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1068 CRESTHAVEN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0809
Mailing Address - Country:US
Mailing Address - Phone:901-866-8864
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3452
Practice Address - Country:US
Practice Address - Phone:901-448-6650
Practice Address - Fax:901-302-2486
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38005207W00000X
TN65999207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR288529001Medicaid
TNQ076585Medicaid
MS200001086Medicaid
MO200116317Medicaid