Healthcare Provider Details

I. General information

NPI: 1790890341
Provider Name (Legal Business Name): CLARK BEEMAN FULLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 3RD ST SUITE 975W
LOS ANGELES CA
90048-6101
US

IV. Provider business mailing address

8635 W 3RD ST SUITE 975W
LOS ANGELES CA
90048-6101
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-0530
  • Fax: 310-652-9936
Mailing address:
  • Phone: 310-652-0530
  • Fax: 310-652-9936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG76647
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG76647
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: