Provider Demographics
NPI:1932178951
Name:FULLMAN, JEFFREY D (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:FULLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1411 SW MORRISON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1945
Mailing Address - Country:US
Mailing Address - Phone:503-242-9850
Mailing Address - Fax:503-279-8157
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:STE 110
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7452
Practice Address - Country:US
Practice Address - Phone:503-692-1205
Practice Address - Fax:503-692-1207
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-07-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD13393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR282301Medicaid
OR282301Medicaid
OROOWCZBLBMedicare ID - Type Unspecified