1134436041 NPI number — DR. MICHELLE K. FUKUMOTO PH.D.

Table of content: DR. MICHELLE K. FUKUMOTO PH.D. (NPI 1134436041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134436041 NPI number — DR. MICHELLE K. FUKUMOTO PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUKUMOTO
Provider First Name:
MICHELLE
Provider Middle Name:
K.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134436041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 283249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-594-6217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 UNIVERSITY AVE.
Provider Second Line Business Practice Location Address:
SUITE #403
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-594-6217
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY-1502 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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