=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053418715
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM M.K. FULLMER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10800 LOCKWOOD DR
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20901-1554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-697-5336
-----------------------------------------------------
Fax | 508-697-1599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 APPLETREE CIR
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02324-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-697-5336
-----------------------------------------------------
Fax | 508-697-1599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 03493
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2173
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104556486
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------