Provider Demographics
NPI:1922089721
Name:FUKUDA, CHRISTOPHER SHIGERU (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SHIGERU
Last Name:FUKUDA
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 1:1101 26TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5161
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:1101 26TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5161
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39098208800000X
MT86520208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F29201Medicare UPIN
VTVN0374Medicare PIN
VT0VN0374Medicaid