Healthcare Provider Details

I. General information

NPI: 1508134263
Provider Name (Legal Business Name): DR. LUCIAN FULGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2011
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 WILSHIRE BLVD
BEVERLY HILLS CA
90212-3415
US

IV. Provider business mailing address

9100 WILSHIRE BLVD
BEVERLY HILLS CA
90212-3415
US

V. Phone/Fax

Practice location:
  • Phone: 877-801-6325
  • Fax: 877-801-6325
Mailing address:
  • Phone: 877-801-6325
  • Fax: 877-801-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number12640
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number4975
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: