Provider Demographics
NPI:1851349120
Name:FULLER, CATHERINE G (MD)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:G
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11645 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1150
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1708
Mailing Address - Country:US
Mailing Address - Phone:310-828-7978
Mailing Address - Fax:310-909-1911
Practice Address - Street 1:11645 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1150
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1708
Practice Address - Country:US
Practice Address - Phone:310-828-7978
Practice Address - Fax:310-909-1911
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43782207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA43782FOtherPTAN
CAWA43782FOtherPTAN
CAF14584Medicare UPIN