Provider Demographics
NPI:1083740401
Name:FUKUDOME, EUGENE YOSHIO (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:YOSHIO
Last Name:FUKUDOME
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:MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - Street 2:55 FRUIT STREET, WACC 435
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-726-2066
Mailing Address - Fax:
Practice Address - Street 1:MASSACHUSETTS GENERAL HOSPITAL
Practice Address - Street 2:55 FRUIT STREET, WACC 435
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235136208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery