Healthcare Provider Details

I. General information

NPI: 1093848335
Provider Name (Legal Business Name): JOHN D FUGATE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491NORTH NORTHERN NAVAJO MEDICAL CENTER
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160 NORTHERN NAVAJO MEDICAL CENTER
SHIPROCK NM
87420
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-7038
  • Fax:
Mailing address:
  • Phone: 505-368-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1063
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: