Provider Demographics
NPI:1245219575
Name:FULLMER, MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:FULLMER
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 1:16300 SAND CANYON AVE., #612
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618
Mailing Address - Country:US
Mailing Address - Phone:949-753-1001
Mailing Address - Fax:949-753-1115
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:SUITE 612
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:949-753-1001
Practice Address - Fax:949-753-1115
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47690174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG47690AMedicare PIN