Provider Demographics
NPI:1649240557
Name:FULLMER, CLARK J II (DPM)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:J
Last Name:FULLMER
Suffix:II
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2590
Mailing Address - Country:US
Mailing Address - Phone:701-456-6000
Mailing Address - Fax:
Practice Address - Street 1:2615 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601
Practice Address - Country:US
Practice Address - Phone:701-456-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND60213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14953Medicaid
AZ5926920001Medicare NSC
ND14953Medicaid
NDN714845Medicare PIN
U69071Medicare UPIN