Healthcare Provider Details

I. General information

NPI: 1952720104
Provider Name (Legal Business Name): TIMOTHY RICHARD FULLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W THOMAS RD # 400
PHOENIX AZ
85013-4407
US

IV. Provider business mailing address

240 W THOMAS RD STE 301
PHOENIX AZ
85013-4407
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-6262
  • Fax: 602-406-6261
Mailing address:
  • Phone: 602-406-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberT1068
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberT1068
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number28833
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number73815
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: