Provider Demographics
NPI:1114994738
Name:FULLMER, DANIEL RICHARDS (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:RICHARDS
Last Name:FULLMER
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1501
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-122492085R0202X, 2085R0202X
WAMD000490792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0285030OtherL&I-RADIA REST OF WA
WA0377766OtherL&I-SWEDISH RADIA EDMONDS
ID1114994738Medicaid
4102721OtherBCBS
WA0377759OtherL&I-RADIA KING COUNTY
WA1054630Medicaid
4019715OtherBCBS
WAG8924853Medicare PIN
WA1054630Medicaid
ID1114994738Medicaid
WAG8925228Medicare PIN
WA285030OtherL & I
WA8870540Medicare PIN
WA300124532Medicare PIN
WA8503674Medicaid
4102721OtherBCBS
ID20004820Medicare PIN
4102721OtherBCBS
300124532OtherRR MEDICARE
TN3867101Medicare PIN
WAG8904026Medicare PIN