Healthcare Provider Details

I. General information

NPI: 1174937304
Provider Name (Legal Business Name): DOUGLAS CHARLES FULLERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

9440 BYRON AVE
SURFSIDE FL
33154-2440
US

V. Phone/Fax

Practice location:
  • Phone: 347-875-0165
  • Fax:
Mailing address:
  • Phone: 347-875-0165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number608702
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number608702
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9467663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: