Provider Demographics
NPI:1043671431
Name:FULLER, MATTHEW JOHN (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:FULLER
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 1:3727 BUCHANAN STREET
Mailing Address - Street 2:203
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:95134
Mailing Address - Country:US
Mailing Address - Phone:415-563-1655
Mailing Address - Fax:415-563-1697
Practice Address - Street 1:3727 BUCHANAN STREET
Practice Address - Street 2:203
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:95134
Practice Address - Country:US
Practice Address - Phone:415-563-1655
Practice Address - Fax:415-563-1697
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33457111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor