Provider Demographics
NPI:1164586905
Name:EDWIN B FULLER MD INC
Entity Type:Organization
Organization Name:EDWIN B FULLER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-267-3020
Mailing Address - Street 1:655 EUCLID AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2957
Mailing Address - Country:US
Mailing Address - Phone:619-267-3020
Mailing Address - Fax:619-267-4042
Practice Address - Street 1:655 EUCLID AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2957
Practice Address - Country:US
Practice Address - Phone:619-267-3020
Practice Address - Fax:619-267-4042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC26937207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC26937OtherMEDICAL LICENSE
CAA87123Medicare UPIN