Basic Information
| Provider Information | |||||||||
| NPI: | 1053806497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUKUDA | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | MINORU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | BOX G-BH | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556375 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 345 BLACKSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029064829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014556346 | ||||||||
| FaxNumber: | 4014556532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2018 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD17238 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.