Provider Demographics
NPI:1588151914
Name:FULLAM, LINDSAY ROSE (OD)
Entity type:Individual
Prefix:DR
First Name:LINDSAY
Middle Name:ROSE
Last Name:FULLAM
Suffix:
Gender:F
Credentials:OD
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 1222
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-1222
Mailing Address - Country:US
Mailing Address - Phone:928-486-3307
Mailing Address - Fax:
Practice Address - Street 1:6771 WARNER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-9400
Practice Address - Country:US
Practice Address - Phone:928-486-3307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist