Healthcare Provider Details

I. General information

NPI: 1780789099
Provider Name (Legal Business Name): MICHAEL FULLMER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S 1000 E SUITE 200
PAYSON UT
84651-5590
US

IV. Provider business mailing address

15 S 1000 E SUITE 200
PAYSON UT
84651-5590
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-2800
  • Fax:
Mailing address:
  • Phone: 801-465-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7192373-1204
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1497812721
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: