Healthcare Provider Details

I. General information

NPI: 1902984438
Provider Name (Legal Business Name): JOSEPH FULLMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073
US

IV. Provider business mailing address

26901 BEAUMONT BLVD SUITE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-9060
  • Fax: 248-898-9054
Mailing address:
  • Phone: 947-522-1861
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number271175
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number54513 - 020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number271175
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: