MEDICARE: BRENNA SULLIVAN FULLERTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	259770	MA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2086S0120X	Pediatric Surgery Physician	ME150199	FL

General Provider Information

NPI Number	:	1366741720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENNA SULLIVAN FULLERTON M.D.

Provider Business Mailing Address
First Line	:	1720 S ORANGE AVE STE 500
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-2967
Country	:	US
Telephone Number	:	140-754-0100
Fax Number	:	407-540-1011

Provider Business Practice Location Address
First Line	:	1720 S ORANGE AVE STE 500
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-2967
Country	:	US
Telephone Number	:	140-754-0100
Fax Number	:	407-540-1011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2011
Last Update Date	:	08/20/2021

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