MEDICARE: DR. GRANT Y. FUSATO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD516	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	990348300	OTHER	HI	TRICARE
2	A21764-4	OTHER	HI	HMSA

General Provider Information

NPI Number	:	1821075094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT Y. FUSATO O.D.

Provider Business Mailing Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	B-11
City	:	HONOLULU
State	:	HI
Zip	:	96818-3153
Country	:	US
Telephone Number	:	808-486-9393
Fax Number	:	808-486-9391

Provider Business Practice Location Address
First Line	:	4510 SALT LAKE BLVD
Second Line	:	B-11
City	:	HONOLULU
State	:	HI
Zip	:	96818-3153
Country	:	US
Telephone Number	:	808-486-9393
Fax Number	:	808-486-9391

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	12/19/2017

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