Provider Demographics
NPI:1073587184
Name:FUKUSHIMA, TAKANORI (MD)
Entity Type:Individual
Prefix:
First Name:TAKANORI
Middle Name:
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 1:4030 WAKE FOREST RD
Mailing Address - Street 2:STE 115
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6800
Mailing Address - Country:US
Mailing Address - Phone:919-239-0264
Mailing Address - Fax:919-239-0266
Practice Address - Street 1:4030 WAKE FOREST RD
Practice Address - Street 2:STE 115
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6800
Practice Address - Country:US
Practice Address - Phone:919-239-0264
Practice Address - Fax:919-239-0266
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-01269207T00000X
WVMS001207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891163HMedicaid
PA0014843200004Medicaid
NC1163HOtherBCBSNC
MD699321400Medicaid
WV0089111000Medicaid
OH0129631Medicaid
OH0129631Medicaid
PA0014843200004Medicaid
NC2262691BMedicare PIN