Provider Demographics
NPI:1225243256
Name:FULLWOOD, WILLIAM KOGIRO (IDC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KOGIRO
Last Name:FULLWOOD
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 1:2841 RENDOVA RD # CODEN01H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-5490
Mailing Address - Country:US
Mailing Address - Phone:619-437-2860
Mailing Address - Fax:619-437-2700
Practice Address - Street 1:USS TARAWA LHA 1
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96622 1600
Practice Address - Country:US
Practice Address - Phone:619-556-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-12
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman