Provider Demographics
NPI:1477663284
Name:FUKUMOTO, JON (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:FUKUMOTO
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 1:1329 LUSITANA ST STE 307
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2435
Mailing Address - Country:US
Mailing Address - Phone:808-524-6115
Mailing Address - Fax:
Practice Address - Street 1:1329 LUSITANA ST STE 307
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2435
Practice Address - Country:US
Practice Address - Phone:808-524-6115
Practice Address - Fax:808-528-1711
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 13701207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000262758OtherHMSA
HI586125-01Medicaid
HIH50026Medicare PIN