Provider Demographics
NPI:1104978154
Name:FUKUYAMA, OSAMU (MD)
Entity type:Individual
Prefix:DR
First Name:OSAMU
Middle Name:
Last Name:FUKUYAMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N KUAKINI ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2364
Mailing Address - Country:US
Mailing Address - Phone:808-538-1125
Mailing Address - Fax:808-538-1125
Practice Address - Street 1:321 N KUAKINI ST
Practice Address - Street 2:SUITE 504
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2364
Practice Address - Country:US
Practice Address - Phone:808-538-1125
Practice Address - Fax:808-538-1125
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-4346207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI01053701Medicaid
HI1096-7OtherLOCAL BCBS (HMSA) PROV NO
HI1096-7OtherLOCAL BCBS (HMSA) PROV NO
HI0000BDLLWMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.