Provider Demographics
NPI:1669648408
Name:FAN, RONG (MD)
Entity type:Individual
Prefix:
First Name:RONG
Middle Name:
Last Name:FAN
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 1:1355 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:027-732-3441
Mailing Address - Fax:
Practice Address - Street 1:7455 W WASHINGTON AVE STE 301
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4340
Practice Address - Country:US
Practice Address - Phone:702-732-3441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065131A207ZP0102X
MI4301510501207ZP0102X
NY313196-01207ZP0213X
NV27457207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology