Healthcare Provider Details

I. General information

NPI: 1891328720
Provider Name (Legal Business Name): SELENA FU, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 QUIVIRA RD
OVERLAND PARK KS
66215-2306
US

IV. Provider business mailing address

3147 W 145TH TER
LEAWOOD KS
66224-3755
US

V. Phone/Fax

Practice location:
  • Phone: 917-623-5442
  • Fax:
Mailing address:
  • Phone: 917-623-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SELENA FU
Title or Position: PRESIDENT
Credential: MD
Phone: 917-623-5442