Provider Demographics
NPI:1225285034
Name:FULLER, SHANDI JOYCELYN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANDI
Middle Name:JOYCELYN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 BONITA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1014
Mailing Address - Country:US
Mailing Address - Phone:105-939-1300
Mailing Address - Fax:
Practice Address - Street 1:1918 BONITA AVE STE 200
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1014
Practice Address - Country:US
Practice Address - Phone:510-939-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC97347OtherCERTIFICATION
CAA117119OtherLICENSE