Provider Demographics
NPI:1174937304
Name:FULLERTON, DOUGLAS CHARLES
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CHARLES
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9440 BYRON AVE
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2440
Mailing Address - Country:US
Mailing Address - Phone:347-875-0165
Mailing Address - Fax:
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1003
Practice Address - Country:US
Practice Address - Phone:347-875-0165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608702163W00000X, 367500000X
FLAPRN9467663367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse