Provider Demographics
NPI:1841786829
Name:FULLMER, MATTHEW DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
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 1:1226 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1424
Mailing Address - Country:US
Mailing Address - Phone:541-476-6636
Mailing Address - Fax:
Practice Address - Street 1:1226 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1424
Practice Address - Country:US
Practice Address - Phone:541-476-6636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151010511390200000X
ORDO209577207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology