Provider Demographics
NPI:1093848335
Name:FUGATE, JOHN D (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:FUGATE
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:PO BOX 160
Mailing Address - Street 2:NORTHERN NAVAJO MEDICAL CENTER
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420
Mailing Address - Country:US
Mailing Address - Phone:505-368-7038
Mailing Address - Fax:
Practice Address - Street 1:US HWY 491NORTH
Practice Address - Street 2:NORTHERN NAVAJO MEDICAL CENTER
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1063152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ430257Medicaid
CO08010639Medicaid
NMR4992Medicaid
NMR4992Medicaid
T60827Medicare UPIN