Healthcare Provider Details

I. General information

NPI: 1235573684
Provider Name (Legal Business Name): BRETT CRAIG FUKUMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2013
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date: 04/19/2018
Reactivation Date: 05/01/2018

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12 AVENUE WEST WING 279
MIAMI FL
33136
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-8178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME137690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: