Basic Information
| Provider Information | |||||||||
| NPI: | 1447447818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FU | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924044836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098814520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 03/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | A96100 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207R00000X | A96100 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A961000 | 01 | CA | BLUE SHIELD CA | OTHER |