Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 12991T | CA |
Y | 152W00000X | Optometrist | OPT002431 | GA |
NPI | 1013045368 |
---|---|
Provider Name | Dr. Ricardo Fukuzato |
First Address | San Antonio, TX 78213-1338 |
Second Address | Johns Creek, GA 30097-1509 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2007 |
Last Update Date | 12/01/2009 |