Provider Demographics
NPI:1366507352
Name:FUJIKAWA, MARK ALAN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:FUJIKAWA
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 1:2414 SHATTUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2023
Mailing Address - Country:US
Mailing Address - Phone:510-843-1228
Mailing Address - Fax:510-843-2080
Practice Address - Street 1:2414 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2023
Practice Address - Country:US
Practice Address - Phone:510-843-1228
Practice Address - Fax:510-843-2080
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5524T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055240Medicaid
CASD0055240Medicaid