Provider Demographics
NPI:1821075094
Name:FUSATO, GRANT Y (OD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:Y
Last Name:FUSATO
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 1:4510 SALT LAKE BLVD
Mailing Address - Street 2:B-11
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3153
Mailing Address - Country:US
Mailing Address - Phone:808-486-9393
Mailing Address - Fax:808-486-9391
Practice Address - Street 1:4510 SALT LAKE BLVD
Practice Address - Street 2:B-11
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3153
Practice Address - Country:US
Practice Address - Phone:808-486-9393
Practice Address - Fax:808-486-9391
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI990348300OtherTRICARE
HIA21764-4OtherHMSA
HIU76562Medicare UPIN
HI52988Medicare ID - Type Unspecified
HI990348300OtherTRICARE