Provider Demographics
NPI:1235573684
Name:FUKUMA, BRETT CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:CRAIG
Last Name:FUKUMA
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 1:1611 NW 12 AVENUE
Mailing Address - Street 2:WEST WING 279
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-8178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-28
Last Update Date:2019-05-08
Deactivation Date:2018-04-19
Deactivation Code:
Reactivation Date:2018-05-01
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL1376902085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program