Provider Demographics
NPI:1013045368
Name:FUKUZATO, RICARDO (OD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:FUKUZATO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1338
Mailing Address - Country:US
Mailing Address - Phone:812-285-5050
Mailing Address - Fax:
Practice Address - Street 1:11720 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1509
Practice Address - Country:US
Practice Address - Phone:770-495-7898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12991T152W00000X
GAOPT002431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist