Healthcare Provider Details

I. General information

NPI: 1205354073
Provider Name (Legal Business Name): PATRICK FULGENCIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 BROOKSHIRE AVE
DOWNEY CA
90241-4917
US

IV. Provider business mailing address

6105 ORANGEGATE DR
YORBA LINDA CA
92886-5217
US

V. Phone/Fax

Practice location:
  • Phone: 562-904-5000
  • Fax:
Mailing address:
  • Phone: 714-609-3060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A17169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: