Provider Demographics
NPI:1053806497
Name:FUKUDA, ANDREW MINORU (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MINORU
Last Name:FUKUDA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:345 BLACKSTONE BLVD
Mailing Address - Street 2:BOX G-BH
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4800
Mailing Address - Country:US
Mailing Address - Phone:401-455-6375
Mailing Address - Fax:
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4829
Practice Address - Country:US
Practice Address - Phone:401-455-6346
Practice Address - Fax:401-455-6532
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD172382084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry