Provider Demographics
NPI:1487711966
Name:FULLAR, MICHAEL KEEN (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KEEN
Last Name:FULLAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:310 E 24TH ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4030
Mailing Address - Country:US
Mailing Address - Phone:646-942-6162
Mailing Address - Fax:
Practice Address - Street 1:BETH ISRAEL MEDICAL CENTER
Practice Address - Street 2:1ST AVE AND 16TH ST
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-844-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241619-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry