Provider Demographics
NPI:1285632711
Name:FULLER, DONALD B (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:B
Last Name:FULLER
Suffix:
Gender:M
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:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:858-888-7721
Practice Address - Street 1:3366 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5713
Practice Address - Country:US
Practice Address - Phone:619-230-0400
Practice Address - Fax:858-429-7936
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62532174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG62532OtherSTATE LICENSE
CA00G625320Medicaid
CABF0272815OtherDEA CERTIFICATE
CAEY342ZMedicare UPIN
CAWG62532OMedicare PIN
CAWG62532PMedicare PIN
CAWG62532KMedicare PIN
CAWG62532MMedicare PIN
CA00G625320Medicaid
CAG62532OtherSTATE LICENSE
CAWG62532Medicare ID - Type Unspecified