Provider Demographics
NPI:1114667698
Name:FULLERTON, CONNOR MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:MICHAEL
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 S ROOSEVELT CIR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3231
Mailing Address - Country:US
Mailing Address - Phone:605-323-9639
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program