Provider Demographics
NPI:1427210889
Name:FONGUE FONGUE, VIVIEN S (DO)
Entity type:Individual
Prefix:DR
First Name:VIVIEN
Middle Name:S
Last Name:FONGUE FONGUE
Suffix:
Gender:M
Credentials:DO
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 100905
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0905
Mailing Address - Country:US
Mailing Address - Phone:786-662-0600
Mailing Address - Fax:
Practice Address - Street 1:6200 SW 72ND ST
Practice Address - Street 2:SUITE 602
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4828
Practice Address - Country:US
Practice Address - Phone:786-662-0600
Practice Address - Fax:786-533-9419
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272692207X00000X
MO2013002776207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03850373Medicaid