Healthcare Provider Details

I. General information

NPI: 1144592098
Provider Name (Legal Business Name): JOEL ANDREW FULKERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 22190
CAMP PENDLETON CA
92058-2111
US

IV. Provider business mailing address

104 BURROWS CT
OCEANSIDE CA
92058-8363
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-2969
  • Fax:
Mailing address:
  • Phone: 623-225-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0102203655
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: