1164586905 NPI number — EDWIN B FULLER MD INC

Table of content: (NPI 1164586905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164586905 NPI number — EDWIN B FULLER MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWIN B FULLER MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164586905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 EUCLID AVE
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
NATIONAL CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91950-2957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-267-3020
Provider Business Mailing Address Fax Number:
619-267-4042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 EUCLID AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
NATIONAL CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91950-2957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-267-3020
Provider Business Practice Location Address Fax Number:
619-267-4042
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FULLER
Authorized Official First Name:
EDWIN
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
619-267-3020

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  C26937 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C26937 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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