Provider Demographics
NPI:1528002029
Name:FULLMER, RONALD F (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:F
Last Name:FULLMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. FORT ST.
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-422-1325
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST.
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1325
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5186207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001287500Medicaid
IDP00029394OtherRR MEDICARE
IDB63903Medicare UPIN