Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 14374R | LA |
N | 2080P0204X | Pediatric Emergency Doctor | 14374R | LA |
NPI | 1154314904 |
---|---|
Provider Name | Juan M Fukuda |
First Address | Lafayette, LA 70508-6902 |
Second Address | Lafayette, LA 70508-6902 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2005 |
Last Update Date | 04/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1113166 | (05) | LA |
H25419 | (02) | LA |