Provider Demographics
NPI:1053637694
Name:FULLER, COREY BRANDON (MD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:BRANDON
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11406 LOMA LINDA DR STE 226
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3711
Mailing Address - Country:US
Mailing Address - Phone:909-558-6644
Mailing Address - Fax:909-558-6118
Practice Address - Street 1:25455 BARTON RD STE 102B
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3139
Practice Address - Country:US
Practice Address - Phone:909-558-6444
Practice Address - Fax:909-558-6118
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA118405207X00000X, 207XX0005X
FLME137332207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine