1245219575 NPI number — DR. MICHELE FULLMER MD

Table of content: DR. MICHELE FULLMER MD (NPI 1245219575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245219575 NPI number — DR. MICHELE FULLMER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLMER
Provider First Name:
MICHELE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1245219575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16300 SAND CANYON AVE., #612
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-753-1001
Provider Business Mailing Address Fax Number:
949-753-1115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16300 SAND CANYON AVE
Provider Second Line Business Practice Location Address:
SUITE 612
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92618-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-753-1001
Provider Business Practice Location Address Fax Number:
949-753-1115
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G47690 , 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)





Copyright © 2007-2025 www.npivalidator.com