Provider Demographics
NPI:1053447243
Name:SPECTRUM FALLS FOOT & ANKLE SPECIALISTS, PC
Entity Type:Organization
Organization Name:SPECTRUM FALLS FOOT & ANKLE SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-889-7055
Mailing Address - Street 1:2730 S VAL VISTA DR
Mailing Address - Street 2:SUITE 158
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-6675
Mailing Address - Country:US
Mailing Address - Phone:480-889-7055
Mailing Address - Fax:480-889-7054
Practice Address - Street 1:2730 S VAL VISTA DR
Practice Address - Street 2:SUITE 158
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-6675
Practice Address - Country:US
Practice Address - Phone:480-889-7055
Practice Address - Fax:480-889-7054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0484213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU69071Medicare UPIN
AZ5926920001Medicare NSC
AZ114197Medicare PIN