Provider Demographics
NPI:1972666386
Name:FUKUDA, MARK M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
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 1:503 ROBERT GRANT AVE RM 1W30
Mailing Address - Street 2:WRAIR - OFFICE OF RESEARCH MANAGEMENT
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-7500
Mailing Address - Country:US
Mailing Address - Phone:301-319-9940
Mailing Address - Fax:
Practice Address - Street 1:315-6 RAJVITHI ROAD
Practice Address - Street 2:
Practice Address - City:BANGKOK
Practice Address - State:AP
Practice Address - Zip Code:10400
Practice Address - Country:TH
Practice Address - Phone:2542-272-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD30034207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease