Healthcare Provider Details

I. General information

NPI: 1770523540
Provider Name (Legal Business Name): JASPER FULLARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5746 N BROADWAY ST
KANSAS CITY MO
64118-3998
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 816-912-4539
  • Fax: 855-813-6642
Mailing address:
  • Phone: 248-824-6600
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-16758
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberR7174
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number04-16758
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR7174
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: