Provider Demographics
NPI:1457753766
Name:FULTON, DAVID JR
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:FULTON
Suffix:JR
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 1:11120 E OCEAN AIR DR STE 101-29
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4683
Mailing Address - Country:US
Mailing Address - Phone:858-224-2945
Mailing Address - Fax:
Practice Address - Street 1:3430 FIFTH AVE STE 3
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5019
Practice Address - Country:US
Practice Address - Phone:858-224-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116108101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health