Healthcare Provider Details

I. General information

NPI: 1689193443
Provider Name (Legal Business Name): ROBERT FU IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE BLDG 14
SAN DIEGO CA
92134-7000
US

IV. Provider business mailing address

1638 ARROYO SIERRA DR
SANTA ROSA CA
95405-7766
US

V. Phone/Fax

Practice location:
  • Phone: 707-230-0807
  • Fax:
Mailing address:
  • Phone: 707-230-0807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: