Provider Demographics
NPI:1033188560
Name:FULWIDER, COLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:MARIE
Last Name:FULWIDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3772 KATELLA AVE.
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-6428
Mailing Address - Country:US
Mailing Address - Phone:562-430-4294
Mailing Address - Fax:562-493-3573
Practice Address - Street 1:3772 KATELLA AVE.
Practice Address - Street 2:SUITE 206
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-6428
Practice Address - Country:US
Practice Address - Phone:562-430-4294
Practice Address - Fax:562-493-3573
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37354207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37354AOtherPTAN
CAA47051Medicare UPIN
CAG37354AOtherPTAN