Provider Demographics
NPI:1184796401
Name:FULLMER, JASON (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:FULLMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11111 RESEARCH BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5264
Mailing Address - Country:US
Mailing Address - Phone:512-380-9200
Mailing Address - Fax:512-380-9201
Practice Address - Street 1:11111 RESEARCH BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5264
Practice Address - Country:US
Practice Address - Phone:512-380-9200
Practice Address - Fax:512-380-9201
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-12-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXL08002080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154700203Medicaid
TXL0800Medicare UPIN