1457349144 NPI number — DEBRA FULLAN D.O.

Table of content: DEBRA FULLAN D.O. (NPI 1457349144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457349144 NPI number — DEBRA FULLAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLAN
Provider First Name:
DEBRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1457349144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4905 W TILGHMAN ST
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18104-9130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-866-9583
Provider Business Mailing Address Fax Number:
610-366-1147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4905 W TILGHMAN ST
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18104-9130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-866-9583
Provider Business Practice Location Address Fax Number:
610-366-1147
Provider Enumeration Date:
10/07/2005

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: 207L00000X , with the licence number:  OS007883L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1105125 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01749864 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017498640 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000097909 . This is a "THREE RIVERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0671239000 . This is a "INDEP. BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1105125 . This is a "AMERIHEALTH MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 163943 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0163943 . This is a "KHP CENTRAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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