Provider Demographics
NPI:1790890341
Name:FULLER, CLARK BEEMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:BEEMAN
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8635 W 3RD ST
Mailing Address - Street 2:SUITE 975W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-652-0530
Mailing Address - Fax:310-652-9936
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:SUITE 975W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-652-0530
Practice Address - Fax:310-652-9936
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76647208G00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091070Medicaid
CAF43519Medicare UPIN
CAGR0091070Medicaid