Provider Demographics
NPI:1750467874
Name:FUKUDA, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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:PO BOX 972
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0972
Mailing Address - Country:US
Mailing Address - Phone:909-528-6858
Mailing Address - Fax:909-798-9999
Practice Address - Street 1:721 NEVADA ST
Practice Address - Street 2:SUITE #406
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8079
Practice Address - Country:US
Practice Address - Phone:909-528-6858
Practice Address - Fax:909-798-9999
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77453207Q00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH99603Medicare UPIN
CA00G774531Medicare PIN
CA00G774530Medicare PIN