Provider Demographics
NPI:1952305385
Name:FULSANG, ELISE JAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:JAN
Last Name:FULSANG
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 1:24800 SE STARK ST.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-674-1391
Mailing Address - Fax:503-413-1895
Practice Address - Street 1:300 N GRAHAM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-413-4134
Practice Address - Fax:503-413-1895
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232402Medicaid
OR130413Medicare ID - Type Unspecified
OR232402Medicaid