Provider Demographics
NPI:1447388905
Name:FUKUZATO, PATRICIA GRACE (OD)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:GRACE
Last Name:FUKUZATO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:GRACE
Other - Last Name:BONOMOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3670 HUTCHINSON RD STE A
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-5903
Mailing Address - Country:US
Mailing Address - Phone:678-807-7482
Mailing Address - Fax:678-807-7243
Practice Address - Street 1:3670 HUTCHINSON RD STE A
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-5903
Practice Address - Country:US
Practice Address - Phone:678-807-7482
Practice Address - Fax:678-807-7243
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12940T152W00000X
NY006834TUV152W00000X
GAOPT002423152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV02060Medicare UPIN