Provider Demographics
NPI:1083873905
Name:FULLING, JOHN ALLAN CLAYTON (IDC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALLAN CLAYTON
Last Name:FULLING
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 N POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-3127
Mailing Address - Country:US
Mailing Address - Phone:619-203-7508
Mailing Address - Fax:847-688-2512
Practice Address - Street 1:2410 SAMPSON ST
Practice Address - Street 2:FISHER BMC #237
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-5556
Practice Address - Fax:847-688-2512
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman