Provider Demographics
NPI:1790842110
Name:FUKAGAWA, NAOMI K (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:K
Last Name:FUKAGAWA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 PHEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7745
Mailing Address - Country:US
Mailing Address - Phone:802-985-5495
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF VERMONT
Practice Address - Street 2:89 BEAUMONT AVENUE, GIVEN BUILDING C-207
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-0001
Practice Address - Country:US
Practice Address - Phone:802-656-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48073208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTB85508Medicare UPIN