Provider Demographics
NPI:1497764864
Name:FUKUDA, KENNETH ATSUO (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ATSUO
Last Name:FUKUDA
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 1:9615 NIGHTINGALE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7234
Mailing Address - Country:US
Mailing Address - Phone:714-403-1395
Mailing Address - Fax:
Practice Address - Street 1:6270 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-2103
Practice Address - Country:US
Practice Address - Phone:949-786-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11134T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist