Provider Demographics
NPI:1073543740
Name:FUKUSHIMA, BRIAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:FUKUSHIMA
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 1:5316 S WOODROW ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5838
Mailing Address - Country:US
Mailing Address - Phone:801-747-1020
Mailing Address - Fax:801-747-1023
Practice Address - Street 1:5316 S WOODROW ST STE 200
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5838
Practice Address - Country:US
Practice Address - Phone:801-747-1020
Practice Address - Fax:801-747-1023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5280409-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005772401Medicare ID - Type Unspecified
UTH96575Medicare UPIN