Provider Demographics
NPI:1295964195
Name:FULLERTON, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:P.O. BOX 716
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:724-662-2650
Mailing Address - Fax:724-662-1338
Practice Address - Street 1:737 GREENVILLE RD
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:PA
Practice Address - Zip Code:16137-5070
Practice Address - Country:US
Practice Address - Phone:724-662-2650
Practice Address - Fax:724-662-1338
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016025207Q00000X
PAOT013079390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102753757Medicaid