=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134126568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL G FULLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2005
-----------------------------------------------------
Last Update Date | 03/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26250 EUCLID AVE SUITE 611
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44132-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-261-2606
-----------------------------------------------------
Fax | 216-261-9814
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26250 EUCLID AVE STE 611
-----------------------------------------------------
City | EUCLID
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44132-3693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-261-2606
-----------------------------------------------------
Fax | 216-261-9814
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 35041455F
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------