=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689218208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOREY FUKUI OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2019
-----------------------------------------------------
Last Update Date | 11/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 PHYSICIANS BLVD BLDG D
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93301-5840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-327-4499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1730 BRADBURY DR
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-235-3625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 34459TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------