Provider Demographics
NPI:1811168032
Name:FULLERTON, SUSAN BLUMHAGEN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BLUMHAGEN
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 OLD SAW MILL RD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3355
Mailing Address - Country:US
Mailing Address - Phone:203-380-8605
Mailing Address - Fax:
Practice Address - Street 1:44 OLD SAW MILL RD
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3355
Practice Address - Country:US
Practice Address - Phone:203-380-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-15
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035896208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics