Provider Demographics
NPI:1003023425
Name:FULLMER, MARK DOUGLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:FULLMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 AINSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4105
Mailing Address - Country:US
Mailing Address - Phone:530-755-3200
Mailing Address - Fax:530-755-3205
Practice Address - Street 1:471 AINSLEY AVE
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4105
Practice Address - Country:US
Practice Address - Phone:530-755-3200
Practice Address - Fax:530-755-3205
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20590111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0205900Medicaid
CA1811084973OtherFACILITY NPI NUMBER
CAGDC000590Medicaid
CAU19278Medicare UPIN
CADC0205900Medicare PIN
CA1811084973OtherFACILITY NPI NUMBER
CAZZZ251352Medicare ID - Type UnspecifiedGROUP MEDICARE #