Provider Demographics
NPI:1295919728
Name:BRIAN W FUKUSHIMA MD PC
Entity type:Organization
Organization Name:BRIAN W FUKUSHIMA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-747-1020
Mailing Address - Street 1:5323 SOUTH WOODROW STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-747-1020
Mailing Address - Fax:801-747-1023
Practice Address - Street 1:5323 SOUTH WOODROW STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-747-1020
Practice Address - Fax:801-747-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5280409-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057724Medicare PIN
UTH96575Medicare UPIN