Basic Information
| Provider Information | |||||||||
| NPI: | 1174547814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUKUTAKI | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 460541 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802460541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036673249 | ||||||||
| FaxNumber: | 6023027925 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W GABILAN ST | ||||||||
| Address2: | |||||||||
| City: | SALINAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939012762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317580181 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 26842 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | G147227 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 50652 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01268424 | 05 | CO | MEDICAID | 111271 | 05 | AZ | MEDICAID | 260048251 | 01 | CO | RAILROAD MEDICARE | OTHER |