Provider Demographics
NPI:1780789099
Name:FULLMER, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FULLMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S 1000 E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-5590
Mailing Address - Country:US
Mailing Address - Phone:801-465-2800
Mailing Address - Fax:
Practice Address - Street 1:15 S 1000 E
Practice Address - Street 2:SUITE 200
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-5590
Practice Address - Country:US
Practice Address - Phone:801-465-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7192373-1204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1497812721Medicaid