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NPI Code Detail

MEDICARE: DR. MICHAEL CHARLES GONZALEZ FULLER MD

MEDICARE: DR. MICHAEL CHARLES GONZALEZ FULLER MD
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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1407659683
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MICHAEL CHARLES GONZALEZ FULLER MD
Provider Business Mailing Address
First Line : 5225 23RD AVE S
Second Line :
City : FARGO
State : ND
Zip : 58104-7927
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5225 23RD AVE S
Second Line :
City : FARGO
State : ND
Zip : 58104-7927
Country : US
Telephone Number : 406-202-5134
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/31/2025
Last Update Date : 05/26/2026

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