Provider Demographics
NPI:1821099110
Name:FULLERTON, SHANNON DEE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 LONGWATER DR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1632
Mailing Address - Country:US
Mailing Address - Phone:781-878-5200
Mailing Address - Fax:
Practice Address - Street 1:51 PERFORMANCE DR
Practice Address - Street 2:ENTRY 2
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3141
Practice Address - Country:US
Practice Address - Phone:781-682-8000
Practice Address - Fax:781-335-1412
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205500207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
042297845OtherUNITED HEALTH CARE
042297845OtherMULTI-PLAN/PHCS
1821099110OtherNEIGHBORHOOD HEALTH PLAN
205500OtherTUFTS/TMP
AA279482OtherHARVARD PILGRIM
042297845OtherGIC/UNICARE
042297845OtherTRICARE
042297845OtherHCVM/FIRST HEALTH/COVENTRY
9034507OtherCIGNA
976196 08OtherNETWORK HEALTH
MA1821099110Medicaid
1821099110OtherFALLON
7151128OtherAETNA
SS0128OtherBCBSMA
976196 08OtherNETWORK HEALTH
1821099110OtherNEIGHBORHOOD HEALTH PLAN