Provider Demographics
NPI:1831100965
Name:FULLEMANN, SUSAN L (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:L
Last Name:FULLEMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1820 OGDEN DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-5384
Mailing Address - Country:US
Mailing Address - Phone:650-697-7202
Mailing Address - Fax:650-697-7059
Practice Address - Street 1:1820 OGDEN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-5384
Practice Address - Country:US
Practice Address - Phone:650-697-7202
Practice Address - Fax:650-697-7059
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2011-02-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG51875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52105Medicare UPIN
CA00G518751Medicare PIN