Provider Demographics
NPI:1154382463
Name:FULLER, NICHOLAS S (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1590 ROSECRANS AVE
Mailing Address - Street 2:STE D357
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-3727
Mailing Address - Country:US
Mailing Address - Phone:310-883-3388
Mailing Address - Fax:951-461-7074
Practice Address - Street 1:120 S SPALDING DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1800
Practice Address - Country:US
Practice Address - Phone:310-385-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83197207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG83197BMedicare PIN
CAAZ636Medicare PIN