Healthcare Provider Details

I. General information

NPI: 1114667698
Provider Name (Legal Business Name): CONNOR MICHAEL FULLERTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

2501 S ROOSEVELT CIR
SIOUX FALLS SD
57106-3231
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0076
  • Fax:
Mailing address:
  • Phone: 605-323-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: