Provider Demographics
NPI:1205822905
Name:FULLERTON, ALBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:L
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 1:604 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-2982
Mailing Address - Country:US
Mailing Address - Phone:781-935-3710
Mailing Address - Fax:781-935-3410
Practice Address - Street 1:604 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-2982
Practice Address - Country:US
Practice Address - Phone:781-935-3710
Practice Address - Fax:781-935-3410
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA375142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11117OtherHPIP
MA0172375Medicaid
MA701381OtherTUFTS
C05131Medicare ID - Type Unspecified
B97177Medicare UPIN