Provider Demographics
NPI:1437190139
Name:FUKUMURA, GLEN TOMIO (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:TOMIO
Last Name:FUKUMURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2600 REDONDO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2329
Mailing Address - Country:US
Mailing Address - Phone:562-988-7349
Mailing Address - Fax:562-988-7190
Practice Address - Street 1:2600 REDONDO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2329
Practice Address - Country:US
Practice Address - Phone:562-988-7349
Practice Address - Fax:562-988-7190
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA43686208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics