Provider Demographics
NPI:1497528236
Name:FULLERTON, DERONTE
Entity Type:Individual
Prefix:
First Name:DERONTE
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 E 219TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1102
Mailing Address - Country:US
Mailing Address - Phone:216-703-0348
Mailing Address - Fax:
Practice Address - Street 1:17325 EUCLID AVE STE 4012
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1262
Practice Address - Country:US
Practice Address - Phone:216-438-3349
Practice Address - Fax:216-250-8148
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator