Provider Demographics
NPI:1710002498
Name:FUKUNAGA, SHELLY A (OD)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:A
Last Name:FUKUNAGA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2130 REDONDO BEACH BLVD.
Mailing Address - Street 2:SUITE G
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504
Mailing Address - Country:US
Mailing Address - Phone:310-538-9797
Mailing Address - Fax:310-538-1725
Practice Address - Street 1:2130 REDONDO BEACH BLVD.
Practice Address - Street 2:SUITE G
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504
Practice Address - Country:US
Practice Address - Phone:310-538-9797
Practice Address - Fax:310-538-1725
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA10849T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10849TOtherSTATE LICENSE NUMBER