Provider Demographics
NPI:1154314904
Name:FUKUDA, JUAN M (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:FUKUDA
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6902
Mailing Address - Country:US
Mailing Address - Phone:337-521-9027
Mailing Address - Fax:337-521-9164
Practice Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6902
Practice Address - Country:US
Practice Address - Phone:337-521-9027
Practice Address - Fax:337-521-9164
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2011-02-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA14374R174400000X, 2080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1113166Medicaid
LA1113166Medicaid