Provider Demographics
NPI:1568491850
Name:FONG, WAYLAND BEN (MD)
Entity type:Individual
Prefix:DR
First Name:WAYLAND
Middle Name:BEN
Last Name:FONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 LA CASSIA DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2253
Mailing Address - Country:US
Mailing Address - Phone:208-343-6495
Mailing Address - Fax:208-343-6496
Practice Address - Street 1:808 LA CASSIA DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2253
Practice Address - Country:US
Practice Address - Phone:208-343-6495
Practice Address - Fax:208-343-6496
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC36879Medicare UPIN