Provider Demographics
NPI:1306846498
Name:FULLER, EDWIN B (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:B
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC26937207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC26937OtherSTATE LICENSE
CA00C269370Medicaid
CAA87123Medicare UPIN
CA00C269370Medicaid