Provider Demographics
NPI:1588756266
Name:FULLERTON, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:FULLERTON
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 1:1700 CALIFORNIA ST
Mailing Address - Street 2:SUITE 470
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109
Mailing Address - Country:US
Mailing Address - Phone:415-202-9990
Mailing Address - Fax:415-843-0548
Practice Address - Street 1:1700 CALIFORNIA ST
Practice Address - Street 2:SUITE 470
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109
Practice Address - Country:US
Practice Address - Phone:415-202-9990
Practice Address - Fax:415-843-0548
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE72097Medicare UPIN
CA00G590002Medicare PIN