Healthcare Provider Details

I. General information

NPI: 1154382463
Provider Name (Legal Business Name): NICHOLAS S FULLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S SPALDING DR SUITE 301
BEVERLY HILLS CA
90212-1800
US

IV. Provider business mailing address

1590 ROSECRANS AVE STE D357
MANHATTAN BEACH CA
90266-3727
US

V. Phone/Fax

Practice location:
  • Phone: 310-385-7755
  • Fax:
Mailing address:
  • Phone: 310-883-3388
  • Fax: 951-461-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG83197
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG83197
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: