Provider Demographics
NPI:1578693875
Name:FUKUMOTO, DAVID E (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:FUKUMOTO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 E SPRING MEADOWS CIR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7667
Mailing Address - Country:US
Mailing Address - Phone:928-699-3532
Mailing Address - Fax:928-527-9414
Practice Address - Street 1:4100 E SPRING MEADOWS CIR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7667
Practice Address - Country:US
Practice Address - Phone:928-699-3532
Practice Address - Fax:928-527-9414
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist